f *VW}W ^3t* jf & ^ THE SURGICAL TREATMENT OF CHRONIC SUPPURATION OF THE MIDDLE EAR AND MASTOID OPPENHEIMER A TYPE OF A NORMAL TEMPORAL BONE, SHOWING A PRONOUNCED CONVEXITY OF THE MASTOID PROCESS. THE L SURGICAL TREATMENT OF CHRONIC SUPPURATION OF THE MIDDLE EAR AND MASTOID" 7 BY SEYMOUR &PPENHEIMER, M.D. Otologist and Laryngologist to Gouverneur Hospital; Otologist and Laryngologist to Mount Sinai Hospital Dispensary; fellow of the American Laryn- gological, Rhinological and Otological Society, Etc, ILLUSTRATED BY FORTY-SIX HALF-TONE PLATES CONTAINING SIXTY-FOUR FIGURES AND TWENTY-SEVEN KEY PLATES, ALL ENGRAVED FROM ORIGINAL DRAWINGS PRE- PARED FROM SPECIAL DISSECTIONS UNDER THE SUPERVISION OF THE AUTHOR PHILADELPHIA P. BLAKISTON'S SON & CO IOI2 WALNUT STREET 1906 COPYRIGHT, 1906, BY P. BLAKISTON'S SON & Co. Pint of TNI New EKA PRIPITHC C LAUCMTEI, PA. TO DR. JULIUS RUDISCH THIS VOLUME IS DEDICATED AS A TOKEN OF ADMIRATION AND RESPECT. PREFACE. Otological problems have during the last decade assumed a clearer aspect, as the result of a better understanding of morbid processes within the middle ear and its communi- cating cells. The application of broad surgical antiseptic principles in the management of suppurative processes in this locality has greatly aided the study of chronic suppura- tive otitis media with its intracranial and mastoidal compli- cations. With the perfection of diagnosis, much has been done in aiding the practitioner to take active measures in order to obtain the radical cure of the suppurating ear and with the conditions present in a given case promptly recognized before serious intracranial or vascular changes have occurred, a great step forward has been taken in its ultimate cure. Special attention has therefore been paid here to the diag- nosis of the various morbid alterations present in this con- dition, as upon such diagnosis, made either previous or during the course of operation, will the exigencies of surgical treat- ment be based, whether this be but the mere removal of a small particle of granulation tissue from the tympanic cavity, viii Preface. or the entire evisceration of the middle ear and mastoid process with exposure of the brain coverings and venous channels. It has also been desired to carry out the plan of taking the lesser conditions found in the usual case of chronic aural suppuration, and from this as a basis, gradually increasing the scope of the pathological alterations found present and the more extensive surgical treatment, until one reaches the complete mastoid operation with its various modifications, and then following this by a description of the plastic opera- tions used to aid in healing the cavity made in the temporal bone and also those suggested for more or less cosmetic reasons. With this plan in view and at the same time emphasizing the most important features of this monograph, that of the surgery of chronic suppurative otitis media, it is hoped that it may be of value in at least making clear some of the difficult problems which are constantly arising in the treat- ment of this most important disease. My sincere thanks are due my friend, Dr. S. J. Kopetzky, for the painstaking aid given me in the preparation of the original dissections for the illustrations. S. O. 45 EAST SIXTIETH STREET, NEW YORK, December, 1905. CONTENTS. PART I. CHAPTER I. INTRODUCTORY 5 CHAPTER II. PRELIMINARY PREPARATION OF THE PATIENT FOR OPERA- TION 33 CHAPTER III. THE TREATMENT OF THE MUCOSA AND MUCO-PERIOSTEUM OF THE TYMPANIC CAVITY 41 CHAPTER IV. THE TREATMENT OF THE OSSICLES 83 CHAPTER V. THE TREATMENT OF CARIES OF THE TYMPANIC WALLS, THE EPITYMPANUM AND HYPOTYMPANUM 133 ix x Contents. CHAPTER VI. THE AFTER-TREATMENT OF OPERATIONS THROUGH THE EXTERNAL AUDITORY CANAL 155 PART II. CHAPTER I. ANATOMICAL AND SURGICAL LANDMARKS 179 CHAPTER II. PRELIMINARY PREPARATION OF THE PATIENT FOR OPERA- TION 227 CHAPTER III. THE SIMPLE MASTOID OPERATION 235 CHAPTER IV. THE RADICAL MASTOID OPERATION 277 CHAPTER V. MODIFICATIONS OF MASTOID OPERATIONS 323 CHAPTER VI. THE RETRO-AURICULAR OPENING AND PLASTIC METHODS.. . 343 CHAPTER VII. THE AFTER-TREATMENT OF MASTOID OPERATIONS 391 INDEX . 411 LIST OF ILLUSTRATIONS. PLATE. PAGE. I. The relations of the facial nerve to the ossicles, and the attic to the cerebral fossa 12 II. The position of the drum membrane and its relations to the osseous auditory canal 16 III. The external auditory canal with the contents of the tympanic cavity exposed 24 IV. The relations of the facial nerve and foot plate of the stapes. Also the tympanic opening of the Eustachian tube 28 V. View of the tympanic cavity showing a retracted cicatrix 48 VI. View of the tympanic cavity showing an adhesive process between the drum membrane and pro- montory 50 VII. View of the tympanic cavity illustrating the cutting of adhesions 52 VIII. A normal drum membrane; a retracted drum mem- brane ; capillary congestion of the drum membrane ; xii List of Illustrations. PLATE. PAGE - effusion behind the drum membrane before and after inflation; an oval-shaped perforation of the drum membrane 60 IX. Multiple and healed perforations of the drum mem- brane 64 X. Perforations of the drum membrane, ossicular necrosis, and polypi 7 XI. Ossicular necrosis and calcareous deposits 76 XII. Caries of the ossicles 90 XIII. Caries of the ossicles 94 XIV. The removal of the malleus no XV. The removal of the incus 116 XVI. Necrosis of the malleus and polypus 122 XVII. Necrosis of the osseous canal wall, absence of the incus and stapes, and perforation of the drum membrane. 138 XVIII. A type of normal temporal bone 184 XIX. Sagittal section of the mastoid process and tympanic cavity, showing the relations of its nerves, muscles and ossicles 188 XX. The course of the carotid artery through the petrous portion of the temporal bone 194 XXI. The internal surface of the temporal bone exposing the internal ear 198 XXII. External surface of the temporal bone of the infant. . 204 XXIII. Internal surface of the temporal bone of the infant. . . 210 XXIV. Cross section of a temporal bone of the pneumatic type. 214 XXV. Cross section of a temporal bone of the diploic type . . 220 XXVI. The primary retro-auricular incision 246 XXVII. The primary incision carried down to the bone expos- ing the field of operation 250 List of Illustrations. xiii PLATE. PAGE. XXVIII. The external cortex of the mastoid removed and the antrum opened 256 XXIX. The completed simple mastoid operation 266 XXX. The completed radical mastoid operation 284 XXXI. The course of the facial nerve in its bony canal and its relations to the tympanic cavity 300 XXXII. The completed radical mastoid operation with an ex- posure of the sigmoid sinus and the middle cerebral fossa 316 XXXIII. The incisions for making the Koerner flap 350 XXXIV. The completed Koerner flap 352 XXXV. The first incision in the Jansen modification of the Stacke flap operation 356 XXXVI. The second step in the Jansen modification of the Stacke flap operation 358 XXXVII. The second incision in the Jansen-Stacke flap opera- tion 360 XXXVIII. The completed Jansen-Stacke flap operation 362 XXXIX. The first step in the Passow-Trautman plastic opera- tion 370 XL. The second step in the Passow-Trautman plastic opera- tion 372 XLI. The completed Passow-Trautman plastic operation . . . 374 XLII. The first step in the Mosetig-Moorhof plastic opera- tion 378 XLIII. The second step in the Mosetig-Moorhof plastic operation 380 XLIV. The third step in the Mosetig-Moorhof plastic opera- tion 382 XLV. The completed Mosetig-Moorhof plastic operation. . . . 384 PART I. OPERATIONS THROUGH THE EXTERNAL AUDITORY CANAL CHAPTER I. INTRODUCTORY. INTRODUCTORY. When a chronic suppurative otitis media does not respond to the varied forms of local treatment and topical applica- tions commonly in use, after long and persistent care, the question in a certain proportion of such cases will arise as to the advisability of surgical treatment and whether the pathological conditions present in the individual case, indi- cate the removal of the altered tissues through the external auditory canal or by the more extensive mastoid operation in its simplest form, or its complicated and varied modi- fications up to the complete so-called radical operation or evisceration of the mastoid and tympanic contents. The object of operative procedures by way of the audi- tory canal is primarily to secure free drainage and to remove necrotic and carious tissue when such is present in the tym- panic cavity in limited and easily accessible areas, thus often removing parts of the auditory conducting mechanism and at the same time carrying out the well known surgical prin- ciple of removing obstructions to the thorough evacuation of purulent collections. By these means provided the tym- panic focus of infection is limited and available to such 5 6 Suppuration of the Middle Ear. instrumentation, the causes which keep up the discharge are removed with the elimination of the diseased bone and the surgical cleanliness which may then be obtained. In addi- tion to removing the necrotic tissue and carious bone, another object obtained is the prevention of marked mastoid changes, especially by extracting the malleus, incus and curetting the tympanic cavity and thus by securing free drainage with added facilities for ingress to the heretofore inaccessible parts lying above and behind these ossicles. Ludewig, with many others, claims that in this way the mastoid operation can often be avoided and in 100 such cases which he reports, 80 per cent, were cured of the suppuration, while with no untoward results as regards facial paralysis he was able to secure in 75 of the series an improvement in hearing an added factor of importance. In addition to the removal of the ossicles and curetting the granulation tissue usually present, one is often enabled to obtain a permanent cure by removing a part of the necrosed Rivinian segment with curette, or, better, the for- ceps chisel, while in another group of cases the object of this operation through the external canal is in addition to remov- ing the cause of the continued suppuration, the relief of more serious symptoms of a septicaemic nature as shown by oscillations in the temperature or continued temperature slightly above the normal and indicative of the accumula- tion or retention of purulent debris. In selected cases of chronic suppuration persisting in spite of ordinary non- operative measures, intratympanic operation is undoubtedly most promising and is also remarkably free from risk either to the patient or his hearing. While it must be borne in mind that in practically all cases of long standing, diseased bone is always present, yet when the carious areas are con- fined to the two larger ossicles or parts of the tympanic walls accessible through the canal, excision and curettage Introductory. 7 presents an almost ideal form of operation, as its perform- ance is comparatively simple and safe and in a large per- centage of such cases a permanent cure may be confidently expected. Further than this, it presents the advantages of requiring no external wound, does not keep the patient inca- pacitated for any length of time as does the mastoid opera- tion and in occasional cases as will be more fully mentioned later, local instead of general anaesthesia alone may be required. The essentials for successful results in ossiculectomy depend of necessity upon many factors, and while it is nec- essary as general principles to perfect thorough cleanliness, with perfect drainage and the removal of all diseased tissue as far as possible from the tympanic cavity, yet the careful selection of cases in which, as far as can be determined, the suppuration is limited to the ossicular chain or its immediate vicinity, or cases in which the presence of marked choles- teatoma can be excluded, is requisite. A certain proportion of failures of necessity will occur even under such circum- stances, and it is always advisable when this operation is indicated and has been urged upon the patient, to fully state to him that while the diseased tissue may be removed and the suppuration cured, yet such cannot be confidently prog- nosticated and is not always sure on account of hidden and inaccessible foci of caries, which may at a subsequent date render a mastoid operation necessary. Unless the condi- tion of the external auditory canal permits, even with appar- ent indications for ossiculectomy present, it will be impos- sible to succeed until the canal has been suitably treated or is of sufficient width to allow of the introduction of the instruments. It is therefore essential that a low grade stenosis or fibrous atresia of the canal be relieved before such operative procedures can be performed and in case this is not possible, the mastoid operation will become a necessity 8 Suppuration of the Middle Ear. in order to reach the middle ear. In old otorrhceas which have not received proper attention, it is not infrequently the case that the canal in part or its greater entirety, is found to be filled with exuberant granulation tissue and of course this must be removed previous to any intratympanic opera- tion. Careful antiseptic cleansing for some time in advance will often greatly aid in reducing the granulation tissue, but often it becomes necessary to remove the growth with snare, curette or cautery, not only to obtain available working space, but it is also highly important to remove as far as possible anything which will add to the bleeding and thus obscure the field of vision. After the canal has been restored to a fairly normal condition, it will then become possible to attack the affected tissues causing the suppuration. Should no fistulous openings be found along the walls of the canal or in Shrapnell's membrane and the location of the aural discharge be somewhat obscure, it may be almost taken for granted in a not inconsiderable number of cases, that the pathological changes are situated somewhere in the upper and posterior portion of the middle ear and careful probing after the parts are cleansed with a fine cannula and syringe, will usually disclose the existence of granulation tissue, lim- ited areas of caries and epithelial and cheesy debris. An additional point of considerable importance in ascertaining the anatomical landmarks within the middle ear for diag- nostic and operative purposes, careful note should be made in the individual case of the axis of the external auditory canal in relation to the horizontal plane of the head and especially so if the patient is in the recumbent position, since in this way only can be obtained a fairly accurate criterion of the relative location of the tympanic contents. In relation to operative procedures, one should always bear in mind a fact that is so often forgotten, namely, that the purulent discharge should be looked upon as a symptom Introductory. 9 of the pathological conditions present and not as the actual disease itself. The presence of the suppuration indicates either the presence of granulation tissue or polypi; choles- teatoma formation; the retention and possible caseation of pus in inaccessible parts of the tympanum or accessory cavi- ties or in loculi and depressions of the bony walls ; or it often implies a carious process in the middle ear and in relation to this it is sometimes kept up by a chronic inflammation of the external auditory canal or by morbid tissue changes of varying sorts in the nasal chambers or nasopharynx. Irre- spective of these conditions but closely associated with them, the otorrhcea may at times be simply the result of a deficient tissue vitality, or an increased microorganismal potency ; the operative results in such cases being greatly enhanced by preliminary treatment directed towards stimulating and increasing the nutrition of the affected tissues and also by such measures as will lessen the activity of the particular organisms present. The odor of the discharge can rarely be relied upon as an indication of necrosed bone unless it is unusually persistent following careful local cleansing of the tympanic cavity, when in the absence of other symptoms, such a condition may be suspected although more often it implies the presence of a retained irritating secretion or of a mass of desquamated epithelium undergoing fatty trans- formation. When such a discharge is persistent, however, it may indicate retained decomposition products which can- not be reached by way of the canal, necessitating recourse to a more extensive operation, especially if the discharge should cease for a time and again recurring at intervals of a few weeks or even months, should be preceded by pain and examination should reveal the presence of a perforation in the flaccid membrane with extensive changes in the region of the attic. While it is not desired or even contemplated here to io Suppuration of the Middle Ear. describe the anatomy of this region, yet it is required to mention certain points, the knowledge of which are essen- tial to the successful performance of intratympanic opera- tions, and also to emphasize the necessity of the thorough realization to the otologist of the finer and detailed anat- omical landmarks as especially related to the surgical path- ology of this region. Usually for purposes of localization, the membrana tympani is divided into the four well known segments, but Fougeray has found it of more service to divide the drum head into but two parts, by an imaginary line horizontally placed and passing almost over the round window. For intratympanic study as concerns us here this is quite practicable, and if one will carefully examine an ear with this in mind, it will be found that practically all the important structures are placed above this line. It is essen- tial in this connection, however, to realize that the angle formed by the manubrium and this horizontal line varies in different positions of the head. As far as the tympanic cavity itself is concerned, it is best to consider it as consist- ing of three parts exclusive of the accessory cavities; the superior portion of attic being bounded inferiorly by the tendon of the tensor tympani muscle and the facial canal in its horizontal portion, and containing the body of the incus and the head of the malleus. Further than this, the epitym- panic space may be described as that portion of the tympa- num superior to a horizontal line passing through the short process of the malleus. The tegmen (see plate I) is situated a short distance above the annulus, giving attachment to the membrana tympani, and it is important to bear in mind in every case of chronic suppuration that the tympanic roof is not always intact, both on account of irregular dehiscences which occur in this position and also on account of the petro- squamous suture, which is sometimes so incompletely closed at this point that an intimate relation amounting to almost EXPLANATORY NOTE TO PLATE I. An original anatomical section showing the relations of the facial nerve to the ossicles and the relations of the attic and its contents to the cerebral fossa. The tegmen tympani is noticed as being exceptionally thin. i, Tegmen tympani ; 2, ossicles and attic ; 3, drum membrane ; 4, external auditory canal ; 5, mastoid cells which have been excavated ; 6, facial nerve exposed ; 7, mar- ginal rim of drum membrane ; 8, aquaeductus Fallopii. 12 PLATE I Introductory. 13 close contact of the dura mater and tympanic mucous mem- brane is permitted. The external wall of this portion of the tympanum is composed in part of the flaccid membrane and a large part of the osseous wall, the pars ossea. The atrium or middle portion of the tympanic cavity embraces that part lying internally to the membrana tympani and its bony supporting wall, and while it does not possess the same surgical importance as the attic, the ofttimes ex- treme thinness of its labyrinthine or inner wall suggests the precaution of great care in removing granulation tissue or necrotic areas from its surface. The atrium is separated from the tympanic vault by the body and neck of the malleus, the anterior and external ligaments and the numerous redu- plications of the mucous membrane. The latter often is so thrown into folds and reduplications that the upper cham- ber is so completely shut off from the lower, that even air cannot pass from one to the other ; this factor being of great importance in chronic suppurative processes. It is here in the upper portion of the flaccid membrane that we occa- sionally find a perforation communicating with one of these mucous pockets just above the short process, or slightly pos- terior to it, or still more infrequently above the anterior liga- ment. The floor of the tympanum or hypotympanic space is situated below and behind the inferior border of the sulcus tympanicus and in front is in close proximity to the internal carotid artery, while posteriorly it bears a similar close relation to the jugular fossa. (See plate II.) As a result of the morbid changes which take place, it is often difficult to accurately localize the ossicular land- marks ; this is especially so when a portion of the manubrium has been destroyed by caries, so that it appears as if worn away to a stump ending suddenly below the short process, or again, it may have an irregular appearance and show a sharp point. The short process of the malleus is by far the 14 Suppuration of the Middle Ear. most important landmark to be first sought out, as it usually remains in its normal position, and from it as a basis the manubrium can be located, even as is commonly found that this portion of the malleus is necrosed so that it is drawn inwards or upwards by fibrous bands, or even partially obscured from view by the thickened anterior and posterior folds, or by an unusually prominent short process. Val- uable information may be ordinarily obtained from the char- acter and anatomical location of the perforation in the mem- brana tympani and especially by the study of the perforation when located in the flaccid portion of this membrane where it is almost invariably indicative of necrosis of the malleus and ofttimes of the incus. As has been shown by Politzer, perforation of Shrapnell's membrane is produced in the majority of cases by the inflammation involving the entire middle ear, while later it may be localized only to the external attic. In these cases there are often present adhesions be- tween the membrana tympani and the inner tympanic wall, this being strongly suggestive of antral suppuration. The perforation may be in almost any part of this membrane, but it is more frequently central and the neck of the malleus may be exposed, the vessels in the neighborhood of the short process and the handle of the malleus are injected, while as the result of an encapsulated pus collection, Prussak's space may be filled and the posterior segment of the membrana tympani may be bulging into the lumen of the canal. The local septic condition thus produced by the encapsulation of cholesteatomatous material or pus cells in one of these numerous mucous membrane folds, leads to destruction not only of a portion of the ossicular chain, but also to parts of the osseous walls adjacent to the segment of Rivinius, thus producing defects of the osseous continuity of the upper wall of the auditory canal. These defects when present vary in size from that of a pin head to a gap above the short process, EXPLANATORY NOTE TO PLATE II. An original anatomical section showing the position of the drum membrane and its relations to the osseous auditory canal. The tympanic cavity is opened laterally. i, Membrana tympani, with malleus; 2, osseous auditory canal opened; 3, tympanic cavity opened exposing the promontory ; 4, acute (lower) angle formed by the drum membrane with the floor of the auditory canal ; 5, carotid canal ; 6, tegmen tympani ; 7, obtuse (upper) angle formed by the drum membrane with the auditory canal. 16 PLATE II Introductory. 17 exposing a great part of the attic, after the purulent secre- tion, epithelial masses or granulations which usually fill it, have been removed. In cases that have resisted the usual local treatment, but in which the suppuration continues without apparent exten- sion of the morbid process to any marked degree, the per- foration in the membrana flaccida indicates serious attical changes in the nature of partial ossicular caries or caries of the attical walls, with often retained pus, granulation tissue and cholesteatoma. These cases may be relieved or even cured in some instances by removing the remains of the tympanic membrane and larger ossicles, with, in some cases, excision of the outer attic wall. Posterior perfora- tions of the membrana tympani are usually attended with considerable discharge remaining unchanged in amount after long treatment and often accompanied with a marked degree of impairment of hearing. They are significant often of caries of the incus, especially of its articular process and the perforation may extend in such a direction either supe- riorly or inferiorly, that the head of the stapes can be readily recognized. Perforations of the anterior segment of the membrana tympani seem to be usually associated with a more profuse purulent discharge than is found with per- forations in other parts, and they are also found most fre- quently in a group of cases in which the tympanic suppu- ration bears an intimate relation with catarrhal changes in the Eustachian tube (see plate IV), nasopharynx and nasal chambers. In these cases, caries of the tip of the manu- brium is often associated, which does not necessarily require surgical treatment, nor is excision of the ossicles demanded in this group as frequently as when the perforation is situated elsewhere, as when there is retention of the decomposed products of purulent formation, a fair percentage show a 3 1 8 Suppuration of the Middle Ear. permanent cure under antiseptic treatment with incision of the membrana sufficient to obtain good drainage. According to Leutert who has made some valuable obser- vations relative to the surgical importance of tympanic mem- brane perforations, the surgeon must determine the seat of suppuration in the tympanum and also as to the presence or absence of diseased bone. He classes these cases of chronic suppurative otitis media under four headings: Sup- puration of the middle ear; suppuration of the Eustachian tube and nasopharynx; suppuration of the attic; and sup- puration of the antrum. As regards the presence or absence of diseased bone in the middle ear, the discharge may be associated with disease of the ossicles or with disease of the bony walls of the drum cavity and he claims it is possible to recognize this by the position of the perforation in the membrana tympani. When the perforation is in the pos- terior upper quadrant, it indicates isolated caries of the long limb of the incus ; if it is in the flaccid membrane and extends to the periphery, it shows that there is caries of the roof of the antrum, the posterior wall of the antrum and the inner- most part of the posterior wall of the external auditory canal. Should the perforation involve the flaccid membrane directly above the short process, one would be led to suspect caries of the head of the malleus, and if it is behind the short process, it indicates caries of the incus; while if not entirely in the membrane but also extends into the osseous wall of the attic, it shows that there is a carious condition of the head of the malleus; when this perforation in the bone ex- tends backwards, both the malleus and incus are carious, with a probable implication of the antrum. When there remains some peripheral remnants of the membrana tympani with the handle of the malleus projecting free into the tym- panic cavity, there is probably an absence of caries of the incus, as drainage is free and retention of pus does not take Introductory. 19 place. When the perforation is found in the lower ante- rior quadrant, the carious area is in the same position on the tympanic wall and in those cases where the perforation reaches to the anterior periphery about the middle of the drum, the Eustachian tube plays a prominent part in the suppurative process. With caries of the anterior part of the attic not involving the ossicles, the perforation will be in the periphery of the tympanic membrane and extending to the anterior attical wall, and when the perforation is in the lower segment of the membrana tympani but not extend- ing to the periphery, one can exclude extensive disease of the cavities adjacent to the tympanum. The perforations which do not involve the periphery of the lower portion of the tympanic membrane, are characteristic of isolated sup- puration in the drum cavity and an operation on the ossicles is usually contraindicated, as it will not expose the focus of the disease and in this group it is only those cases where the perforation is peripheral, that is, when the disease is located on the postero-superior or antero-inferior wall of the tympanic cavity, that operation through the canal will expose the infected focus to direct treatment, and it should also be remembered in these cases that the treatment should be most conservative. Closely associated with the pathological alterations of the middle ear and playing a prominent part in the results obtained by operation through the auditory canal, is the tympanic mucous membrane, which also plays the part of a periosteum especially to the ossicles which entirely derive their nutrition through its vessels and when by changes in the periosteum this is diminished or entirely abolished, caries inevitably takes place. The retention of pus by the numer- ous folds of the mucosa is also of considerable surgical im- portance, but it is desired only to mention briefly these facts here, as they will be treated of later in greater detail. 20 Suppuration of the Middle Ear. The inner tympanic wall is of great importance. Con- siderable variation of opinion exists as to whether it should be left undisturbed in the event of gross pathological changes of its mucosa on account of the supposed danger to the important labyrinthine structures which it separates from the tympanic cavity, or whether it should be curetted from the same as other portions of this chamber, when such measures seem to be apparently indicated, equally good authorities on both sides of this question being in favor of such measures, while others are strongly opposed to it. It seems, however, that with the exercise of due care and with regard to the landmarks upon it, there are no good rea- sons why diseased tissue should not be removed from here as well as from any other parts of the tympanic cavity, and one can hardly appreciate the view that a mass of exuberant granulation tissue should be allowed to remain, when it jeopardizes the entire results of an otherwise successful intratympanic operation. On account of the comparative frequency of natural or pathological dehiscences of the tympanic roof, great caution should be exercised in any manipulations here during the removal of the ossicles or curetting the walls of the tympanum, for if one should pene- trate to the dura under such circumstances, a fertile field for infection will be opened up, and what was a compara- tively benign operative procedure, will necessitate a more formidable opening of the broken down area to possibly pre- vent an infective intracranial process taking place. The surgical relations of the roof of the tympanum are therefore of great importance, as it is formed by the petrosquamous suture and with the vault of the antrum is in close relation with the middle cranial fossa and the former especially sup- ports in front the temporosphenoidal lobe of the cerebrum. The relations of the attic (see plate III) both to the tym- panum proper and to the aditus and antrum, make it essential Introductory. 21 in the majority of cases of chronic suppuration which come to operation, that free drainage be thoroughly effected. There is a small group of cases in which varied signs point to a gen- eral mastoid sclerosis, yet radical operation is apparently not indicated and in instances of this nature, the drainage of the attic should be obtained by the excision of the membrana tym- pani, ossicles and such granulation tissue that may be present. Another group which is not infrequent, shows evidences of a limitation of the residual suppurating process to the attic or epitympanic space and in such cases great difficulty may be experienced in locating the minute perforation which is always found in the membrana flaccida. The purulent dis- charge is often a mere suspicion of moisture, just sufficient to annoy the patient. As a result of its scant quantity it rapidly dries and forms crusts in the immediate vicinity of the perforation in the superior quadrant of the membrana and neighboring wall of the canal. A drop of partially inspissated pus may sometimes be discovered covering the perforation, or again a minute polypus may seem to be emerg- ing through it and lead to the belief that the polyp forma- tion is probably single, when further search, especially after removing a portion of Shrapnell's membrane or enlarging the perforation, will reveal the attic filled with granulation tissue. When these cases are seen quite late, that is, after they have existed for a long period of time, the larger part of the tympanic cavity seems to be free from any evidences of active pathological processes, although the alterations in the mucous membrane especially, clearly signify the existence of previously active suppurative changes, the existent attical suppuration to all intents being the residual localization of the affection. As the epitympanic recess is in major part partitioned off from the body of the tympanum proper even in the natural state by the irregularly placed and horizontal 22 Suppuration of the Middle Ear. reduplications of the tympanic mucous membrane and por- tions of the two larger ossicles with their ligaments which bring them into close association with the osseous walls of the cavity and these structures combined form a definite floor for the attical space, it can readily be appreciated that although a part of the tympanic cavity, yet from a surgical aspect it is in great part distinct and as such, should be con- sidered more in the light of an accessory chamber. Under such circumstances, the hyperplastic changes which take place in the structures forming its floor after the disease has continued for a length of time, necessarily renders it prac- tically an isolated cavity and when epithelial debris or puru- lent material is retained here, the drainage is entirely impos- sible by natural means and unless relieved by operation through the canal, will produce an extension of the morbid changes posteriorly through the antrum into the mastoid cells. In practically all cases at this stage, the antrum and adjacent mastoid regions are involved to some extent, but rarely to the degree necessitating a mastoid operation and in a lesser number of cases, the perforation in the flaccid mem- brane increases in size as the eroding process of the retained products of degeneration goes on and in addition, caries of the malleus and incus in part takes place. Should, however, the perforation withstand the pathological process and re- maining small, prevent proper drainage, with marked thick- ening of the folds of the flaccid membrane, the margo tym- panicus will largely bear the brunt of the pathological changes and this border of the squama forming the upper portion of the tympanic ring becomes necrosed and reveals a largely exposed attic space. As has been already men- tioned, the aditus and antrum bear a close surgical and anatomical relationship to these attical suppurations, being located as they are at the posterior and superior angle of the tympanum and forming the passage of communication be- EXPLANATORY NOTE TO PLATE III. An original anatomical section showing the external auditory canal as seen from in front and above. The tympanic cavity with its contents exposed. i, Tegmen tympani ; 2, ossicles; 3, tympanic membrane; 4, external auditory canal ; 5, mastoid cells ; 6, aditus ad antrum. 24 PLATE III Introductory. 25 tween it and the mastoid cellular system. It is well to remem- ber at this point, that slightly projecting at the entrance of the antrum from the tympanic aspect is the osseous process designated the spina tegminis, which is sometimes apt to interfere with the removal of the incus by its projecting ledge catching the hook used for this purpose. While the facial nerve (see plate IV) assumes most active importance in the complete mastoid operation, it also neces- sitates attention although subsidiary, in conditions demand- ing instrumentation through the external auditory canal. With but a minimum of care it may readily be avoided in intratympanic surgery, although occasional cases are observed in which it is extremely liable to be injured. In the middle part of its course for a distance approximating about fifteen millimeters, it is separated from the mucous mem- brane of the tympanic cavity by a comparatively thin shell of osseous tissue, the Fallopian canal crossing the posterior border of the tympanic ring at the angle where an imaginary horizontal plane drawn through the umbo of the membrana tympani extends to the posterior wall of the osseous audi- tory canal. Here the facial canal varies in distance from two to three millimeters from the surface of the posterior wall of the auditory canal, while the continuation of the nerve outside of the tympanum still retains its superficial position in the posterior wall of the canal for about five milli- meters further, being here about three or four millimeters from the surface, then following its course deeply downward and inward to the depth of the bone to reach its exit at the stylomastoid foramen. The most frequent source of dan- ger to the facial nerve is the exposure in part by dehiscences in the walls of the Fallopian canal, thus subjecting it to trau- matism in rare cases even in competent hands. Clefts, as already mentioned, may leave various important and even vital structures in relation with the tympanic cavity exposed, 26 Suppuration of the Middle Ear. and the removal of an area of granulation tissue protecting the dehiscence may result in serious damage from an exten- sion of the inflammation, or when the jugular vein is thus exposed serious hemorrhage may be produced. The carotid artery may also be exposed by such an opening in the bone, protected possibly by only a thin layer of mucous membrane or fibrous tissue, which often inefficiently fills up the gap made by the bone defect, or the roof of the tympanum or antrum may be deficient, allowing the dura to become ex- posed, especially if the mucosa of this part be destroyed by suppurative changes. The recognition of the alterations produced by caries and necrosis, when the major landmarks have also in part been destroyed, is often a matter of considerable difficulty, al- though when the membrana vibrans remains intact and there is found a perforation in Shrapnell's membrane above the short process of the malleus with or without the presence of granulation tissue, one can be fairly accurate in regarding the presence of dead bone as certain, with the possibility also of the malleus being destroyed. At first in order to recog- nize the presence of caries or necrosis, especial attention should be directed to the depths of the external auditory canal and careful search should be made around the entire circumference of the membrana tympani. With care, no harm can be done with a delicate blunt tipped probe cau- tiously exploring the various parts of the entire tympanic space, and in cases of long standing, where the mucous mem- brane is extensively disorganized, the parts are not at all sensitive. Local anaesthesia may be necessary for thorough exploration. It is very important to ascertain as accurately as possible whether the purulent discharge actually origi- nates from any exposed surface of osseous tissue or mucosa, or whether a greater focus of necrosis is in a more inacces- sible part such as the attic or posteriorly in the aditus. EXPLANATORY NOTE TO PLATE IV. An original anatomical section showing the relation of the facial nerve and the foot plate of the stapes ; also the Eustachian tube, its isthmus and tympanic opening and its relation to the tympanic cavity. i and 2, Facial nerve ; 3, fenestra ovalis with foot plate of stapes ; 4, fenestra rotunda ; 5, promontory ; 6, the floor of the tympanic cavity, showing corrugations ; 7, Eustachian tube ; 8, isthmus ; 9, mastoid cells. 28 PLATE IV Introductory. 29 After exploring the lower parts of the tympanum, it has been recommended to carefully insert the probe under the anterior and then the posterior folds of the membrane, in order to carry it upwards and ascertain the condition of the vault. It is often possible in this manner to recognize the presence of dead bone by the peculiar feeling imparted by it to the lightly held probe. Undoubtedly the indications for treatment and especially for surgical treatment are in a general manner based upon the pathological findings. When the affection is practically limited to the tympanum proper, the pus secreting mucous membrane is congested and hypersemic and markedly infil- trated with round cells, which produce considerable thicken- ing in various areas and as the vessels are compressed by the excessive cellular development, nutritive changes take place with the formation of granulation tissue, usually preceded by a degeneration of the cellular constituents in part and the progressive development of fatty metamorphosis. At this time connective tissue bands, forming irregular masses or definite membranous adhesions, are developing and in addi- tion to embedding the malleus and incus in the granulating mass, the round window may become hidden and in occa- sional cases the entire tympanic cavity may become entirely filled, preventing exploration until active treatment so re- duces the mass that the various surgical landmarks can be recognized. As these connective tissue bands are formed by the conversion of the round cells into spindle shaped cells, the ossicles are often found bound together and to the walls of the tympanic cavity and attic by advanced serious tissue alterations. The mucosa of the tympanic walls becomes still more hypertrophied or undergoes polypoid degeneration and it is not uncommon to find the presence of cyst-like spaces from localized areas of degeneration which the membraneous folds have newly developed, or the hyperplasia of the normal 30 Suppuration of the Middle Ear. folds of the mucosa shut off here and there irregular cavi- ties between their walls, which are often entirely isolated and become filled with pus or a purulent like material. Some of these spaces which are quite small finally develop into defi- nite cyst spaces, lined with cylindrical or cubical epithelial cells and containing cholesteatomatous masses mixed with mucin. As a result of the serious involvement of the deeper layers of the mucous membrane which acts as a periosteal covering to the ossicles and walls of the tympanum, this mucoperiosteum shares in the pathological changes and areas of caries and necrosis of the underlying osseous walls takes place, while at this time the malleus and incus together or separately are beginning to become carious. Still later, in addition to the changes just enumerated, an increased de- struction of tissue may take place and the flow of pus from the attic may be observed by its discharge down the long process of the incus, while the antrum at this time is usually involved along with greater or lesser changes in the mastoid. Well developed polypi often lie in the tympanic cavity or project out into the external canal and cholesteatomatous development is not uncommon. As the head of the malleus is suspended and in great part receives its blood supply from the roof of the tympanum, it is less prone to be involved in the carious process than the neck, as this part of the ossicle is liable to remain in con- tinued contact with a purulent collection on account of its close relation with Prussak's space. The formation of the mucous membrane folds in and around this situation and their relation to encapsulated pus collections also plays an important role in the pathology of attical suppuration, de- pending to a marked extent upon the individual variations as to the arrangement of the mucous folds. Very probably the degree of pathological change which takes place is largely influenced by the variety and virulence of the predominating Introductory. 31 microorganism present in the individual case ; it is not desired here to enter into the bacteriology of chronic suppurative otitis media, other than to merely indicate this relation and the important bearing it has upon the question of preliminary treatment of the aural chamber and external canal before operation, but in the majority of cases the streptococcus pre- dominates in the discharge although the pneumococcus is not infrequently found and with more general examination of the secretion in a larger number of cases, it seems highly probable that the tubercle bacillus would be more frequently found to be present. CHAPTER II. PRELIMINARY PREPARATION OF THE PATIENT FOR OPERATION. 33 PRELIMINARY PREPARATION OF THE PATIENT FOR OPERATION. Preliminary to any operation upon the tympanic cavity the general health of the patient should receive most careful attention, as unless this is done the chances of a successful result will be much less than those in an individual otherwise healthy. Attention to the general health, as these cases of long-continued aural suppuration are usually below the nor- mal, means increased tissue resistance and therefore not only more rapid healing of the parts operated on, but also more perfect healing, and if strict attention be paid to this factor, which is often neglected, one will have the satisfaction of seeing the curetted tympanic mucosa, for instance, assume a healthy appearance, instead of, as occurs in the ill-nour- ished individual, the tissues further breaking down and the suppuration continuing after the operation has been cor- rectly performed. Equally as important as attention to the general health of the patient as a preliminary measure of operation, is the careful attention to the nasal chambers and nasopharynx. It is hopeless to expect a perfect result in those cases where there is ozena or a chronic nasopharyngitis 35 36 Suppuration of the Middle Ear. with tubal involvement, if these parts are not placed under as normal conditions as possible, for otherwise we may remove the necrosed malleus and incus and carefully curette the granulation tissue from the tympanic cavity, but if the ear is constantly being reinf ected by the contents of a marked pathological Eustachian tube, the operative procedures will possibly diminish the discharge, but a permanent or even temporary cure will be impossible. The direct care of the patient preliminary to operation consists in rendering as sterile as possible the auricle, external auditory canal and the middle ear. The particular method used varies greatly with different operations and may be from slight cleansing with an antiseptic solution, to the care that is exercised on a mastoid operation; the chances of success being improved by attention to scrupulous cleanliness of instruments, dressings, hands of the surgeon, and as far as possible of the parts to be operated on. It may also be well to mention that the usual rules of surgical asepsis as may be modified to the suppurating cavity should be observed whenever the probe is used in the tympanum for diagnostic or other purposes; a useful and easy method of doing this when operative procedures are not to be performed at the same time is by rendering the canal and as much of the tym- panic cavity as possible (providing there is a large perfora- tion) aseptic, by mopping the parts thoroughly with cotton pledgets saturated with a 1 : 1000 bichloride solution, or if this is contraindicated with a 1 : 50 carbolic acid solution. When the ossicles are to be removed, the external canal should be syringed out several times daily with a solution of bichloride of mercury 1 : 3000 or 1 : 5000, or with a dilute solution of peroxide of hydrogen, saturated solution of boric acid, or a i : 40-60 carbolic acid solution. Just previous to, or at the time of operation, the canal should again be thor- oughly cleansed with the stronger bichloride of mercury Preparation of the Patient for Operation. 37 solution, then the canal is filled with peroxide of hydrogen for a minute or two and again washed with the bichloride solution, when it is thoroughly dried with sterile cotton. In doing this the walls of the canal should be thoroughly scrubbed with a cotton-tipped applicator, and in this manner any pus or desquamated epithelium which remains will be removed. After each cleansing, a strip of sterilized or iodo- form gauze should be introduced into the canal, reaching as far as the drum membrane, and the meatus closed with a tuft of sterile cotton, which should not be removed until the next cleansing unless it becomes stained with discharge, when it should be removed and replaced with a fresh piece. While, of course, it is practically impossible in a sup- purating otitis to render the canal or middle ear aseptic, or in some cases even approximately so, yet we should be most careful to obtain as perfect a degree of surgical cleanliness as possible, both in order to remove septic material and to prevent the added introduction of other varieties of patho- genic microorganisms. It is often surprising to observe the degree of cleanliness that may be obtained in this way, and as has been suggested by Pritchard in this connection, that while it is not always possible to thoroughly sterilize the middle ear, yet if we sufficiently reduce the dose of the septic poison, the natural sterilizing power of the tissues will be enabled to cope successfully with the enemy. In removing polypi or large granulations from the canal or tympanic cav- ity without further operative procedures, a solution of 1 : 3000 bichloride of mercury in alcohol makes a most efficient anti- septic. While the head is inclined, with the ear to be operated on uppermost, a few drops of this solution are placed in the canal, being allowed to remain for some minutes, then re- moved with sterile cotton and this process repeated a number of times, as often as may seem necessary in the particular case. While this acts as an active antiseptic agent, it does 38 Suppuration of the Middle Ear. not irritate nor coagulate the albumenous discharges and at the same time, by its dehydrating property, to some extent, it renders the vascular tissues to be removed lighter in color and reduced in size. When ossiculectomy is to be performed in a hospital ser- vice it is not necessary to specify here any particular method of sterilizing the instruments used, but where such facilities are not possible, one can be certain of the asepsis of his instruments by boiling the larger ones in a I or 2 per cent, bicarbonate of soda solution for five minutes, while the more delicate instruments and knives are placed in the solution for not over a minute and then immersed in alcohol. The ques- tion of anaesthesia in intratympanic operations depends en- tirely upon the amount of tissue to be removed and the forti- tude of the patient. When it is desired to remove a freely exposed malleus or its remnants, or to snare a polypus or a group of exuberant granulation tissue, local anaesthesia is all that is necessary and in a very small number of individ- uals where the affected tissues are not unduly sensitive or the fortitude of the individual is unduly great, even more extensive operative procedures may be accomplished under such circumstances. Local anaesthesia is also amply suffi- cient when a small perforation in the membrana tympani requires enlarging, or when there are a limited number of easily accessible adhesive bands to be destroyed. While there is a great diversity of opinion in regard to the use of local or general anaesthesia for tympanic operations, one may in general state that for the minor procedures as pre- viously mentioned, local anaesthesia is amply sufficient, while for ossiculectomy, with or without curettage of the tympanic walls, general anaesthesia is absolutely necessary. For local anaesthetic purposes, cocaine in from 10 to 25 per cent, solu- tion is almost universally used; a few drops are placed in the ear for fifteen or twenty minutes and the parts are dried Preparation of the Patient for Operation. 39 after the tissues have become insensitive and as the opera- tion proceeds and more inaccessible parts are reached, areas to be further cocainized are touched with a cotton tuft satu- rated with the solution. The objection to this anaesthetic here is that often a considerable amount is necessitated and untoward symptoms may occur if the granulation tissue removed exposes fresh areas by which the drug can be rapidly absorbed. Eucain may, however, be substituted in such cases with considerable satisfaction, or in cases where it is desired to expose the attic in part, Schleich's solution has been used somewhat, injected into the superior wall of the external canal in the immediate vicinity of the area to be operated on. While, when the surface to be operated on is limited in extent, and especially when perforations in the drum require enlargement for drainage, Gray's formula of 10 per cent, cocaine in equal parts of anilin oil and alcohol, has been efficient in my hands in producing a marked degree of anaesthesia in a considerable number of cases. When the patient is nervous or shows signs of consider- able restlessness, a general anaesthetic must be employed, the choice depending almost entirely upon the surgeon. Beco records a case in which he removed the malleus under ethyl bromide anaesthesia, but as a general rule ether or chloroform are to be preferred. As indicated above, gen- eral anaesthesia is always essential when the intratympanic operation is to be of any extent, when carious bone is to be removed or when curetting is practised, as the movements of the patient interfere with the work of the operator. CHAPTER III. THE TREATMENT OF THE MUCOSA AND MUCO-PERIOSTEUM OF THE ? TYMPANIC CAVITY. THE TREATMENT OF THE MUCOSA AND MUCO-PERIOS- TEUM OF THE TYMPANIC CAVITY. In a previous chapter the various pathological changes taking place in the tympanic cavity during the course of a chronic suppurative otitis media, were pointed out in their relation to various changes in the surgical landmarks as de- termining the character of the surgical treatment, especially as indicated by the minute diagnostic features present in a given case. It is here desired to still more forcibly empha- size the complete interdependence between the pathology of this affection and the essential features concerned in its sur- gical treatment. As regards operative procedures through the external canal, the conditions necessitating such will be taken up under the subdivisions of operations upon the mem- brana tympani and operations upon the mucosa and muco- periosteal lining of the tympanic cavity, the latter dealing with hyperplasia, granulation tissue, polypi, and finally cho- lesteatomatous masses susceptible of relief by intratympanic operations, in contradistinction to more extensive forma- tions, which necessitate a radical mastoid operation for their successful amelioration. 43 44 Suppuration of the Middle Ear. While the membrana tympani is affected, both as regards its continuity and structure in all cases of chronic suppura- tion, it is especially desired to call attention here to the sur- gical treatment of perforations and adhesions of this mem- brane as they influence the course of the disease. When the perforation is very small, so that the escape of purulent or mucopurulent masses through it is rendered impossible, or where the symptoms present indicate a partial retention of pus from this cause, it should be enlarged with a small straight or curved knife as the operator may prefer. The canal should be rendered as sterile as possible by the methods previously indicated and with a 10 to 20 per cent, solution of cocaine or the cocaine-anilin oil formula, the perforation and adjacent parts of the membrana tympani are moistened with the anaesthetic for some minutes. Good illumination and preferably the electric photophore is essential, and with the patient in the erect posture, the knife is introduced through the perforation and it is enlarged by an incision, usually downwards towards the floor of the tympanum, in order to obtain the best drainage, or in some cases it may be advisable to enlarge the perforation by an incision from 2 to 5 millimeters long in the direction of any localized bulging of the drum head that may be present. In some instances, where the mucosa alone is affected and necrosis of the ossi- cles or tympanic walls is not present, this slight operation will effectually relieve the retention and may be all the oper- ative procedure necessary to obtain a complete cure, although such a result is but rarely obtained. As a result of the enlargement of the perforation there is a free discharge of the confined purulent secretion, the tympanic cavity is more thoroughly exposed and when the secretion is tenacious and clings to the mucosa, it can thus be more readily removed and later medical treatment of the otorrhcea is thus greatly facilitated. Treatment of the Mucosa. 45 As this represents the most simple operation performed for the relief of chronic suppuration, it often fails to be of any benefit on account of the tympanum being more exten- sively affected than may be expected, or as frequently hap- pens, the favorable results are only transient as the incision into the drum often rapidly closes and the benefits thus obtained are lost. The perforation should be enlarged in the same manner, when it is very small or pouting, and there are minor evidences of retention with redness of the drum and beginning inflammatory phenomena. In addition to the small size of the perforation per se, it may become still more minute by a thickening of its circumference from hyper- plastic changes in the membrana tympani and proliferation of the epithelium around its borders, thus preventing the proper egress of the contained secretion. The perforation should also be enlarged as an initial measure, when there are evidences of cholesteatomatous masses present acting as a plug and obstructing the previously existing perforation, or when granulation tissue in the tympanic cavity acts as a source of obstruction, especially when there also exists some fullness of the drum; and finally the perforation should be amply enlarged in all cases where other operative measures do not appear to be indicated, but in which there is not the necessary space present to cleanse the middle ear or to intro- duce the applicator or syringe to remove retained products of degeneration. When it is found necessary to make a second perforation in the membrana tympani, the operation does not differ in any essentials from that of enlarging the size of a previous perforation, but as the initial incision into the drum head is somewhat painful, although the sensibilities of the tympanic membrane are obtunded after a long period of suppuration, it is well to thoroughly anaesthetize the area to be opened as well as possible with a 20 per cent, warm cocaine solution and with the head of the patient firmly held 46 Suppuration of the Middle Ear. in position, an incision 4 or 5 millimeters long is made in the drum, preferably as low as possible, or wherever bulging, if such be present, is most prominent. In other words, this operation should be performed practically the same as an ordinary myringotomy in acute otitis. As suggested by Politzer, the indications for a second perforation under such conditions are in certain cases where there are adhesions between the membrana tympani and inner tympanic wall (see plate V), where there are isolated loculi containing purulent material and also in those cases where there is considerable bulging of the membrana tympani at some distance from the original perforation, and where there are more or less fre- quent recurring attacks of pain, indicative of a focal area of retention in the deeper parts of the tympanic cavity. As still further indications for the adoption of this measure may be suggested those cases in which at a distance from the original perforation, masses of cholesteatomatous material or polypi or granulations produce an isolated bulging of the membrane, or in perforation of Shrapnelf s membrane if slight symptoms of pus retention are present in the lower tympanic space. For the removal of adhesions between the membrana tympani and the tympanic wall, various small tympanic knives are necessary, especially those with the blade curved at right angles to the shaft. If the perforation in the drum is not sufficiently ample for the necessary manipulations, it may be enlarged as previously mentioned, or the greater part may require removal; but this is rarely the case, as in such instances the drum head is already in great part destroyed. The most frequent form of adhesion of this character, and practically the only one which requires consideration in this connection, is when the tympanic membrane becomes at- tached to the inner tympanic wall and where the posterior margin of the large perforation is firmly adherent to the EXPLANATORY NOTE TO PLATE V. A schematic side view of the tympanic cavity showing a retracted cicatrix and intra-tympanic relations. i, External auditory canal; 2, retracted cicatrix; 3, line of drum membrane; 4, suspensory ligament; 5, attic; 6, incus; 7, malleus; 8, stapes; 9, promontory; 10, hypo-tympanic space. 48 PLATE V EXPLANATORY NOTE TO PLATE VI. A schematic side view of the tympanic cavity showing an adhesive process between the drum membrane and promontory. i, External auditory canal; 2, retracted drum membrane; 3, adhesions between the drum membrane and promontory; 4, promontory. 50 PLATE VI EXPLANATORY NOTE TO PLATE VII. A schematic side view of the tympanum illustrating the cutting of adhesions between the promontory and drum membrane. i, Knife in position; 2, adhesion partly severed. 52 PLATE VII Treatment of the Mucosa. 53 promontory, while the anterior border remains entirely free (see plate VI). When such a condition is found, there is sure to be retention of pus or epithelial debris in the pocket thus formed, with all the symptoms of retention. With an angular knife, it may be possible to dissect away the attached drum from the inner tympanic wall (see plate VII), or in case this is not feasible, the straight knife should be used and the membrana tympani removed at its circumference, the cir- cular incision being made a line or so from the annulus, and it is usually necessary in these cases to also remove the mal- leus, the technique of which will be described in a later chapter. Inasmuch as the mucous membrane of the tympanic cav- ity is in such intimate connection with its contained ossicles and bony walls and as they depend for nutrition upon it, a careful study of the morbid changes of the mucosa is essen- tial to a satisfactory understanding of the rationale of some of the necessary operative procedures. In general, the muco- periosteal lining of the tympanic cavity, including the attic and antrum, may present the various stages of thickening, the development of a granular stage or ulceration, or as more frequently happens all of these changes are found associated in the majority of cases upon which operation is indicated. In color, it may vary from the deep red of chronic conges- tion to a yellow-gray hue from degenerative changes. It is always markedly thickened, and while rarely smooth in ap- pearance, it is more often irregular or elevated into well- formed granulation masses which may be so excessive in development that the entire tympanic cavity becomes filled. When such is the case, one will usually on careful examina- tion find some evidences of involvement of the antrum and pneumatic cells of the mastoid process, thus precluding oper- ation through the canal and strongly indicating the opening of the antrum by way of the mastoid process. The histo- logical changes which have a direct bearing on the develop- 54 Suppuration of the Middle Ear. ment of granulation tissue and are intimately concerned in the production of necrosis and caries, consists principally of the previously described round cell infiltration and in addi- tion the formation of new vascular channels. At first the periosteal layer of the mucosa does not suffer much morbid change, but the subepithelial layer is densely infiltrated and later becomes practically replaced by a dense mass of granu- lation tissue in which the blood vessels become markedly dilated, tortuous and increased in number, rendering the parts extremely vascular, and thus greatly increasing the difficulties of curetting. Later fatty degeneration takes place in certain portions, while in other parts of the tympanic cavity adhesions are formed from the development of bands of newly grown fibrous tissue, which may appear as a more or less elevated, diffuse thickening of the mucosa, or as cicatricial tissue markedly interfering with the removal of the ossicles. Following this, or more frequently accom- panying it, are found ulcerative changes in the mucosa, the breaking down of the tissue in isolated spots with the cutting off of nutrition to the underlying bone and the development of caries. At the same time as the mucosa covering the osseous walls of the tympanum is undergoing these changes, serious damage is also going on in the tympanic membrane, and as a rule, that portion lying between the manubrium and the periphery is most seriously involved. While other portions may be destroyed, the attachment to the annulus tympanicus remains more or less intact, although a crescentic portion alone in this situation may be all that remains of the mem- brane. In long-standing cases where the destruction is very great, the membrane is quite thickened either by a hyper- plasia of the dermoid layer or as a result of a similar change taking place in the mucous membrane forming its internal surface and when this occurs, it is apt to temporarily em- Treatment of the Mucosa. 55 barrass the operator by the profuse bleeding which takes place from its cut surface in removing it, to gain better access to the contents of the tympanum. In considering the indications for ossiculectomy, when the nature of the purulent discharge in the absence of other marked indications assumes some importance, one should always bear in mind that when the mucosa becomes con- siderably altered in structure and its glandular elements are in great part destroyed, the secretion becomes markedly altered in its nature and is apt to be thin, irritating and pos- sibly have an offensive odor. While this is more or less indi- cative of necrotic bone, yet such is not always the case, and if the hearing remains in fair condition, ossiculectomy or curettage may be not at all advisable, when such would be necessary if dead bone were present. In contradistinction to this condition, the mucosa over the inner tympanic wall may present such a degree of hypertrophy that it is projected forward and ofter markedly resembles the congested tym- panic membrane, if such be absent; the proper condition, however, being recognized by the probe and the loss of con- tinuity of the canal wall in the absence of the drum. Two methods of treatment are available for the granular changes in the tympanic mucosa: the curette and cauteriza- tion. After cleansing both canal and middle ear, the mucous membrane is cocainized and if cauterization is desired the parts are thoroughly dried. The galvanocautery produces too much reaction in this location and had better not be used, but very favorable results may be obtained by the careful application of chromic acid to limited areas. The acid is fused on a delicate probe or applicator, and the parts of the mucosa desired are lightly touched, so that several points are made over the tissue and when the applications are con- sidered sufficient, the excess of acid is removed by lightly moistening the parts with a cotton-tipped applicator contain- 56 Suppuration of the Middle Ear. ing an antiseptic alkaline solution. While this treatment will be sufficient in those cases where the changes in the mucosa have not developed into large granulations, or too much tissue alteration has not taken place, yet curettage is usually indicated. With a sharp spoon or curette the tissue is gently removed, especial care being taken in avoid- ing undue force when the promontory wall is curetted, on account of the danger of injuring the important structures within. Unless dead bone is present, care should always be exercised to avoid wounding the periosteal layer of the mu- cosa, and this can readily be avoided by lightly curetting. In treating the tympanum in this way, one should always use a spoon with a stem that is flexible enough to be bent to any angle desired and yet will be sufficiently strong to remove the tissue, it being necessary to often bend the curette to reach otherwise inaccessible parts and at the same time not disturb the ossicular chain. After curettage, or even in some cases when they first come under observation, the vas- cular supply has diminished and sclerotic changes take place with the production of a dermoid appearance of the mucosa, especially of the inner tympanic wall; this is due to the redevelopment of the epithelial layer either from areas which have not been seriously compromised by the suppuration or from extension inwards of the epithelium from the canal. When the surface so transformed is smooth, it indicates the cessation of suppuration at that point and should be care- fully avoided when using the curette, but when the epithe- lium undergoes excessive proliferation and becomes heaped up in layers, indicating a tendency to the so-called cholestea- toma formation, it requires curettage, which will be described under its appropriate heading. Considerable diversity of opinion exists in regard to curetting the tympanic cavity, and while the author is of the opinion as advised here in the treatment of the affected Treatment of the Mucosa. 57 mucosa, that with care no untoward results are produced, yet some objections have been raised against the perform- ance of this operation, especially after ossiculectomy, as it is claimed that the facial nerve may be wounded and damage done to other parts. One can hardly see how it is possible by nonsurgical treatment to restore an enormously thickened and pus-secreting membrane to anything approaching the normal without cauterization or curettage, as in cases which are observed, it will be found that without such measures the progressive stages of tissue destruction as previously outlined will ensue in many cases, and instead of marked benefit being obtained by curettage, ulceration and necrosis will ensue, necessitating the removal of the ossicles and necrosed bone from the tympanic walls. In regard to curet- ting being omitted after ossiculectomy as an essential part of the operation on account of the spontaneous disappearance of the excessive thickening of the mucosa and the recovering of denuded bone with new membrane, the writer is of the opinion that such views are erroneous, and that such a resto- ration to normal does not take place, but that this favorable result can be obtained in practically all cases where such an operation is indicated, only by the careful and thorough cleansing of the tympanic walls by the curette. That cau- terization of the mucosa in this locality is not entirely free from danger is suggested by the cases reported by Alderton, in one of which the application of chromic acid to the mucosa in the vicinity of the Fallopian canal produced a severe attack of facial herpes, while in another case the same pro- cedure produced an intense local inflammation of the facial nerve which was lying exposed beneath the cauterized soft tissue and the facial palsy ensuing was only relieved by a radical operation. Of course these are exceptional instances of untoward results from this procedure, but that in careful hands such can occur, emphasizes the necessity of extreme 58 Suppuration of the Middle Ear. caution. When evidence warrants the belief that the facial nerve is in any way exposed in the tympanum, one should always avoid its vicinity in using the sharp spoon, but when the mucosa demands removal in such situations, this instru- ment may be replaced by the dull wire curette, which will be found of much service for this purpose. Flat, sessile granulations should be curetted away and where the probe has revealed the presence of dead bone beneath, it should also be removed in the manner to be later described, as in that form of granulation tissue springing, not from the mucosa, as has just been described, but from an area of caries, it is impossible to expect any permanent results from the operation until the entire diseased area has been removed ; otherwise within a very short time the granu- lation tissue will again return. When the discharge is very abundant, associated with excessive granulation develop- ment, so that the fundus of the external canal appears filled with the growth and there is also present a foul odor, one is very apt to find a larger area than the tympanum involved, and operation through the canal will be of no benefit, even if it should drain the antrum, as the mastoid cells are also probably affected. When a mass of granulations, associated with a purulent discharge of an irritating character, are found at the posterior end of the tympanum, it is usually indicative that the source of the discharge is in the antrum. The presence of a similar mass apparently originating from a point directly above the membrana tympani, is strongly suggestive that the pathological changes producing the puru- lent discharge are located in the vault of the tympanum, and if recurrence occurs after their removal, ossiculectomy will be necessary to obtain a satisfactory result. While as a rule the mass of granulation tissue found in the middle ear springs from its interior, yet in every case, the possibilities of this vascular tissue originating from without this chamber should EXPLANATORY NOTE TO PLATE VIII. No. i. Normal drum membrane. No. 2. Retracted drum membrane, with thinning of the drum membrane showing the stapedo-incudal articulation and the shadow of the Eustachian tube. No. 3. Capillary engorgement of the drum membrane and handle of the malleus. No. 4. Effusion behind the drum membrane before inflation. No. 5. Effusion behind the drum membrane after inflation. No. 6. An oval-shaped perforation in the inferior portion of the drum membrane. 60 PLATE VIII Treatment of the Mucosa. 61 always be ascertained previous to their removal from the vault, as when the bone of the tegmen becomes eroded, the dura mater over this area rapidly becomes covered with granulation tissue and unless this is ascertained by the care- ful use of the probe, serious untoward results are liable to ensue upon their removal. This factor in its uncertainty, should alone emphasize the necessity for careful asepsis even in the use of the probe in this region, and if the condition mentioned should be found to exist, great care should be taken to avoid infecting the cranial contents during even the most trivial operative procedures in this locality. In their surgical aspect, both polypi and granulations are the result of irritation from the purulent discharge, but they also assume an active part in keeping up the inflammation and act as barriers to the free exit of pus. On this account their early removal is essential, both to obtain necessary drainage and to further diminish the inflammatory changes in the tissues. This is frequently observed in cases where there has been extensive destruction of the membrana vibrans with the attical space crowded with granulations, forming an irregular mammillated cushion over the internal tympanic wall. Under such circumstances the upper edge of the osseous wall above the membrana is softened and in part destroyed and with the membrana tympani should be removed. With the snare the granulations projecting for- ward can be readily removed, while those on the posterior wall and the base of those snared away should be lightly curetted with the sharp spoon, when the probe may then be used to ascertain the presence of areas of carious bone, which should be curetted away in the manner to be later described. Often in these cases where Shrapnell's membrane has been so extensively destroyed, the incus alone, or the malleus as well, shows necrotic changes and in long-standing cases only a remnant of the ossicles will be found, when a complete 62 Suppuration of the Middle Ear. ossiculectomy should be performed, or if examination shows that the carious process has extended backwards and up- wards into the aditus and antrum, it is futile to expect a favorable result unless the antrum be opened by the mastoid route. When an apparent mass of granulation tissue has been removed with snare or curette, one should examine the specimen to ascertain if particles of necrosed bone have been brought away with it and to differentiate it from those rare cases of granuloma in which gritty particles are also found, but which do not indicate the presence of carious osseous tissue. An exceedingly instructive case of this nature is reported by Pierce of a granuloma of Prussak's space simu- lating caries, which occurred over the short process of the malleus and partially obscured this portion of the flaccid membrane from view. The apparent granulation tissue mass was about the size of a pea protruding through the flaccid membrane and the probe showed that it was attached by a small pedicle and in many respects resembled very closely the appearance so characteristic of necrosis of the incus. The growth was removed and the cavity cleaned out with the curette through the opening, and a number of gritty particles were found resembling necrotic bone, but the microscope and chemical tests revealed that the particles were organic and not dead bone. As the presence of necrosis was thus eliminated, the cavity was packed with gauze and complete recovery ensued. In addition to the snare, curette, either sharp or dull, or cautery for the removal of well-developed granulation tissue, one may use for their removal even with greater satisfac- tion, some form of the various cutting forceps, Hartmann's especially being very useful for this purpose. Before intro- ducing the forceps that may seem most acceptable to the operator, the location of the tissue to be removed and its relation to dangerous areas should be accurately determined EXPLANATORY NOTE TO PLATE IX. No. x. Multiple perforation of the drum membrane in a case of tubercular affection of the middle ear. No. 2. Large kidney-shaped perforation, exposing the stapedo-incudal articulation. The tip of the handle of the malleus is also free and the Eustachian open- ing is visible. No. 3. Multiple healed perforations showing transparent cicatrices. No. 4. Large cicatrized perforation in the postero-superior quadrant of the drum membrane. 64 PLATE IX Treatment of the Mucosa. 65 and under good illumination so that the parts operated upon can be easily seen during the entire procedure, the forceps are passed through the perforation in the drum if it will admit them and if not it should be amply enlarged and the tissue desired is bitten off, until all of it has been thoroughly removed. This may be followed up by gently smoothing the more or less ragged surface which is always left, with the sharp curette or should the base of a well-defined granula- tion which has developed polypi formation be present, it is best, after controlling the bleeding and thoroughly drying the parts, to touch it lightly with chromic acid or a strong solution of nitrate of silver. In cauterizing the tissues of the tympanic cavity with any of the more active cauterants, care should always be exercised to destroy only the exact tissue desired and avoiding the contact of the probe contain- ing the cauterant or the galvano-cautery if this should be used, with other parts, both to avoid unnecessary destruction of tissue with a consequent increase in the discharge, which we are endeavoring to diminish ; to prevent excessive inflam- matory reaction by confining the cauterization to as small an area as possible and what is quite as important, to pre- vent giving the patient unnecessary pain. This latter is especially apt to be severe if the dermal lining of the external auditory canal is at all damaged and in cases where the gran- ulation tissue in part extends into the canal, it is better to avoid cauterization and depend entirely for its removal on the curette or cutting forceps, as in addition to the excessive pain produced, which usually lasts for a day or more after the effects of the local anaesthetic have worn away, a most intractable minute ulcer of the canal may persist for a con- siderable time, despite the most active treatment. Another method of removing the excess of the chemical caustic from that previously described is by syringing out the ear with an alkaline or normal saline solution which has been previously 6 66 Suppuration of the Middle Ear. sterilized and thus rendering the further action of the cau- terant inert; it of course not being necessary to do this if the galvano-cautery should be employed. In whatever man- ner the cauterization is performed, always wait until the slough has thoroughly separated from the healthy tissue before another application is made and if necessary this may be repeated several times, care being taken at each cauteriza- tion to render the parts as aseptic as possible to guard against further infection. Synechiotomy, or the division of bands formed by gran- ulation tissue growth in the hyperplastic natural folds of the tympanic mucous membrane, is best performed for the evacuation of retained pus collections, under cocaine anaesthesia with the patient in the erect posture, as it is essential in doing this to have the anatomical landmarks of the middle ear in as near a natural relation as possible. The operation is performed in the same manner as that described for detaching an adherent tympanic membrane from the inner tympanic wall and with curved and straight knives the various bands or adhesions are divided, or if necessary entirely dissected away. It being impracticable to formu- late any set procedure for this operation as every case of necessity presents an extreme degree of variation from each other and each individual must be treated as the particular grouping of the adhesions indicates. Polypi, as the result of the excessive development in a localized area of the inflammatory granulation tissue, are found with a sufficient frequency in long-standing cases of chronic tympanic suppuration to require some mention as to their effects upon the suppurative process and the best methods of eradicating them. Their consistency and there- fore to some extent its effect in determining the manner of their removal, depends upon the amount of fibrous tissue present and from being either hard or soft in texture, they Treatment of the Mucosa. 67 may exceptionally from excessive vascular development as- sume a telangiectatic character and thus be incapable of removal except by the cold snare gradually drawn tight, so that the vascular supply is slowly obliterated. The hot snare has been also advised for this purpose, but when used here where it is of necessity brought into close contact with sur- rounding structures, it has been productive of considerable destruction of tissue, not only from the direct burning of the parts, but also from the irradiation of the heat, and under no circumstances should the galvano-cautery be used in the deeper parts of the external auditory canal or in the cavum tympani. The question of treatment is also greatly influ- enced by the nature of the polypus, that is whether it is pedun- culated or sessile; if the former, it may readily be snared, but when the growth springs from a broad base it usually requires curetting and cauterization. These growths, while increasing the tissue changes in the tympanum, yet are the result of the inflammation of the underlying mucosa from the suppurating process which is going on. These polypi may be either fibrous, mucous or myxomatous in structure, the large majority, however, being designated as the mucous variety, and are readily removed with the cold snare. The effect of such a growth upon the already existing puru- lent process being to markedly exaggerate it by increasing the local irritation, and they also assume a more serious im- portance when of considerable size by obstructing the exit of the purulent discharge from the middle ear, or in some cases, where they may even be very small but located so as to act as a valve to the outflow of the secretion through a perforation in Shrapnell's membrane, serious symptoms of septic retention may be thus produced. When such is the case, the pus is usually foetid or in part inspissated and stained with blood, while the patient may seriously complain of neuralgic pains, vertigo, tinnitus, and even attacks of 68 Suppuration of the Middle Ear. nausea and vomiting, closely resembling in many respects the symptom complex of intracranial mischief, from possibly the retention of but a minute amount of this highly irritating pus. In such cases not only must the polypus be removed, but the perforation in the membrana tympani should also be enlarged to obtain free drainage and sometimes it is nec- essary to perform this procedure first, so that sufficient space is gained to allow of the grasping of the growth by the for- ceps or snare. As regards the removal of polypi springing from the tympanic roof, the same dangers may exist in their removal as has been pointed out in speaking of the growth of granu- lation tissue in this locality, as in some instances such extir- pation may be extremely hazardous as the polyp has devel- oped from the meninges and hangs down into the tympanic cavity, often pushed forward by granulation tissue, so that no suspicion arises other than that it is a growth from the tympanic walls, and when this takes place as the result of an eroded spot in the tegmen tympani or from a congenital dehiscence, pyogenic organisms may thus gain access to the cranial cavity. To prevent the recurrence of the growth, its base after removal should always be cauterized, chromic acid being preferable for this purpose. In addition to this it is essential to prevent as far as possible the absorption of pathogenic microorganisms from the freshly exposed sur- faces, as when the growth is intact this danger is practically nil, but after removal it may be a serious factor in the rapid spread of the purulent inflammation to adjacent structures, by such absorption taking place through the open and ex- posed vessels. To counteract this inflammatory sequela, in addition to the destruction by cauterization of the raw absorbing surface, much may be accomplished by the pre- liminary disinfection of the parts to be operated upon and also by careful after treatment with antiseptic measures to EXPLANATORY NOTE TO PLATE X. No. i. Large perforation in Shrapnell's membrane exposing a carious ossicle. No. 2. Large perforation of the drum membrane exposing the remains of a carious malleus. Inflammatory granulations are visible in the tympanic cavity. No. 3. Large perforation of the drum membrane with an absence of the handle of the malleus. A polypoid excrescence is seen protruding from the tympanic cavity into the external auditory canal. No. 4. Aural polyp protruding from a small perforation at the upper portion of the drum membrane into the external auditory canal. PLATE X Treatment of the Mucosa. 71 reduce to a minimum the virulency of the organisms present and to prevent the redevelopment of further growths. When the attic is involved, and especially when there is caries of the walls, it is not at all uncommon to find a polypus growing from some necrotic spot and projecting outward through the perforation in the membrana tympani, or pro- ducing bulging of the membrana in the vicinity of the per- foration. In this location, or when the polypus grows from the lower tympanic cavity, it becomes practically impossible to remove it with the snare or in fact any instrument until the perforation has been enlarged, or in case the growth is quite large, until the remnants of the tympanic membrane have in great part been removed, when the wire loop can be placed about it if it be pedunculated. Where the hearing is but slightly impaired and in addition to the suppuration, the growth seems to be the only pathological factor of any moment present, if it be small it is sometimes possible with a cotton-tipped probe to push it back into the tympanum, and after ascertaining the location of its base, encircle it with the snare through the perforation; this, however, is not always possible, but is well worthy a trial where it is not desired to disturb the contents of the tympanum any more than is absolutely necessary. In addition to the removal of these inflammatory products by snare, curette, cutting forceps and cautery, they may, when of small size, often be successfully removed with the ring knife, or if of suitable size evulsed with forceps, or detached and removed with the aural hook if at all pedun- culated. While the mucous tissues for all these operative procedures can be fairly well cocainized, yet such is not appli- cable to the dermal lining of the auditory canal, and one should exercise great care, especially in children or nervous individuals, not to allow any instruments that are being used to come into contact with the walls of the latter, as it renders 72 Suppuration of the Middle Ear. the patient extremely restless and may necessitate the use of general anaesthesia, whereas, if care be used, such will gen- erally not be necessary. As general principles in operating upon these growths, one may use the forceps to evulse the masses if they are small and pedunculated and in a position that room is obtainable to carry out this procedure, while the broad-based, small and soft growths may be crushed if it does not seem possible to remove them otherwise, or if any contraindications are present, such as their being situated in a dangerous area. When the polypus or granulation is quite firm and not attached to the underlying parts by a well- defined peduncle, the curette is preferable for its removal, and if it should spring from the malleus or incus, or even from the mucous surface of the membrana tympani, it is always necessary to use the snare if these parts are not to be removed. Should the polypus be attached by a pedicle and originate from the attic or aditus, it will be necessary, in order to grasp it, to bring it lower down if possible, so that it can be readily reached, either with a probe, or if this fails, one of the various forms of incus hooks may often be used successfully and then the loop of the snare suitably curved may be pushed up over the growth until its base is reached, when it can be readily removed. It may be well to mention in this connection that for growths situated lower down in the tympanic cavity, the snare can be used either by drawing tight the loop and cutting through the base of the growth, or when it is desired to evulse the particle of tissue, it may be tightened until the mass within the loop is firmly grasped, and then by a twisting motion the tissue is withdrawn; this method of evulsion, however, can only be practiced when one is certain that it will not also tear away and damage important parts. Where the tissue to be removed is so situated that "this is liable to occur, it is far safer to use the snare by drawing tense the loop until Treatment of the Mucosa. 73 the tissues are cut away in a smooth manner. Undoubtedly in a considerable number of carefully selected cases of chronic otorrhcea in which the presence of dead bone has been excluded, the removal of granulation tissue and polypi will effect a cure. Before concluding these remarks on the surgical treat- ment of this aspect of chronic aural suppuration, it may be well to point out that in using the snare, the kind of wire employed must vary to suit the nature of the tissue to be removed. Steel, copper, brass, silver or soft iron wire is serviceable if the growth can be readily encircled by the loop ; if this is not the case and the tissue is very difficult of access, even a very fine wire of this nature is not sufficiently flexible, and slender brass wire is most satisfactory. For small growths arising from the ossicles or tympanic mem- brane, soft copper or iron wire is usually serviceable, and for somewhat larger polypi a thicker copper or silver wire may be employed. When the growth in part or completely fills the external canal, so that the loop can barely be introduced between it and the wall of the canal, steel piano wire is of most value, as it possesses a certain resiliency which readily adapts it to the conformation of the base of the growth. As a rule, however, the most satisfactory wire that can be used in the great majority of cases, is the fine brass wire, as it is strong, possesses great flexibility, and forms a most satis- factory loop that will readily cut through a firm fibrous poly- pus or tuft of granulation tissue without the least danger of breaking. In practically all cases of chronic suppuration, epithelial hyperplasia takes place to a greater or lesser degree and dependent upon the extent and the accumulation of this epi- thelial debris or cholesteatomatous formation, will the route of operation in many cases be absolutely decided. With the development of these epithelial proliferations, the squa- 74 Suppuration of the Middle Ear. mous cells lining the external auditory canal grow inward through the destroyed area in the tympanic membrane and develop more or less rapidly on the inner tympanic wall and from this point following the course of the air cells of the temporal bone, the process extending upwards and back- wards successively invades the attic, aditus, antrum and in extreme instances, even the mastoid cells. This process, as a pathological phenomenon, may originate at any point at the fundus of the canal where the definite boundary line between the dermal lining and the mucous membrane of the tym- panum has been damaged or destroyed and as the course of the otorrhoea continues, the epithelial cells take on a renewed activity and spreading out in all directions, sooner or later replace the mucosa in great part with a dermal lining. This seems to occur only when the opening in the membrana tympani is in relation with the canal walls, but where the perforation is centrally placed, it does not occur unless the edges of the opening become attached to the inner tympanic wall, when the epithelium then is placed under favorable conditions to extend to the mucosa with which it is in intimate contact. It is essential in studying these cases of chronic suppuration with excessive epithelial develop- ment to ascertain accurately the nature of the growth and its extent, as in this way only will it be possible to select the few cases where operation through the canal will effect a cure from the larger number where the parts must be evis- cerated by way of the mastoid process. Lucien-Barajas has clearly shown this when he states that there are two forma- tions found in the middle ear under this name of cholestea- toma. One is composed of granular, fatty and purulent masses of detritus, intermixed with squamous epithelial cells, keratin and crystals of cholesterin, while the other variety is formed by imbricated nodules concentrically arranged like the layers of an onion. These peculiar nodules, consist- EXPLANATORY NOTE TO PLATE XI. No. i. Large perforation of the drum membrane with caries of the handle of the malleus. The mucous membrane lining the tympanic cavity is covered with granulations. No. 2. Entire absence of drum membrane, malleus and incus. Granulating areas covering the mucous membrane of the tympanic cavity. Nos. 3 and 4. Remains of a chronic suppurative otitis media. The antero-inferior and postero-inferior quadrants of the drum membrane contain calcareous deposits. 76 PLATE XI Treatment of the Mucosa. 77 ing microscopically of large, flat endothelial cells, polygonal in shape, the nuclei stain but faintly, while the masses con- tain a large quantity of cholesterin. The major portion of such cases belong undoubtedly to the first group and must not be classed as true cholesteatoma, nor should similar masses be placed in the same class when composed of poly- stratifications of keratinic epithelial cells, which develop after inflammatory dermal affections of the external auditory canal and which are horny or keratinic formations. On account of endothelial cells being present at certain areas in the tympanic cavity, it is possible in some instances for the affection to originate from such places, but more frequently it is an extension inward of the epithelial elements from the dermal lining of the canal and whatever its source, in order to obtain a satisfactory result it is absolutely essen- tial to select an operation that will radically remove the entire epithelial bearing area of the tympanic cavity and adjacent cells. If the process is limited, then operation through the canal will be perfectly suitable, but if at all extensive, and this is usually the case, such a procedure will inevitably fail. Practically always these epithelial masses of the tympanum are associated with granulation tissue and to a considerable extent also with polypi formation. When this is at all extensive and some degree of purulent reten- tion has existed for a long period of time, removal through the canal while it may relieve the retention, is not productive of beneficial results of any duration, although if no symp- toms of mastoid involvement can be ascertained and the ex- perimental nature of the curetting away of these masses is thoroughly comprehended by the patient, one may occasion- ally in a few cases obtain surprisingly gratifying results, especially if the tympanic cavity be well cleaned out and all foci of epithelial proliferation be thoroughly curetted as far as accessible, with careful after treatment and removal of 78 Suppuration of the Middle Ear. every new particle of epithelial debris as soon as it is recog- nized. An instructive instance of such a result is re- ported by Tresilian, where, in a case of otitis suppurativa of thirty-six years' duration, with associated multiple polypi and cholesteatoma formation, the growths were removed with forceps with recurrence for a time, but ultimately with careful treatment the case was completely cured. The most frequent sites for the redevelopment of the cholesteatoma formation seems to be on the inner tympanic wall and pos- terior surface of the remnants of the tympanic membrane, when but a small portion of it remains around the circum- ference of the annulus. These parts should therefore be carefully watched and on the slightest suspicion of the pres- ence of small irregular globular masses which represent heaped up rapidly proliferating epithelial cells, they should be carefully curetted away. When a considerable portion of the membrana tympani remains with a large central perfor- ation, it sometimes happens that the cholesteatoma develops from the inner layer of the membrane and escapes recog- nition, and thus the focus will remain to increase in size after the rest of the tympanic cavity has been apparently cleansed of the masses; for this reason, therefore, in cases where the condition is capable of removal through the canal, it is always well to remove the remnants of the drum as an initial step and thus prevent to this extent the redevelop- ment of this intractable phenomena of chronic suppuration. While later in the course of the aural affection the antrum becomes filled with cholesteatomatous masses and at the same time caries is nearly always present, some good may be accomplished in individuals refusing operations other than through the canal, by removing the malleus and incus, as will be described later and carefully curetting out the attic. At least, this procedure will markedly aid in the drainage of the parts and may diminish to a considerable extent Treatment of the Mucosa. 79 the purulent discharge, but even in somewhat favorable cases nothing more than this can be hoped for, and inas- much as it is impossible to thus remove all the morbid mate- rial, recurrence will inevitably ensue within a comparatively short time. The best procedure for the cure of such condi- tions when the mastoid cells are not apparently involved is the Stacke operation. The surgical treatment of cholesteatoma necessitates not only the removal of the epithelial masses or the definite neo- plasm, but absolutely requires the thorough destruction of the epithelial bearing foci and scrupulous attention to the after treatment. In small cholesteatoma of the tympanum and involving to some extent the antrum, the desirable results can sometimes be attained by removing through the external canal the pars epitympanica in part, with a strong curette if it be necrosed or with some of the newer modifications of chisel- forceps. In order to avoid repetition, the final method of removing the epithelial bearing foci will be described in detail in speaking of the mastoid operation for this affec- tion. Volkmann's sharp spoon is of great service for scrap- ing out these masses through the external auditory canal, and if used under good illumination, with due regard to the surgical landmarks of this region, the epithelial debris can be most effectually removed. After thus scraping the readily accessible morbid tissue away, the probe should be intro- duced both to ascertain the condition of the newly exposed osseous tissue and also to bring down into the cavity of the tympanum, masses of the tissue which are inaccessible to the spoon. A flexible dull curette bent at the proper angle is often of service for this purpose and when all exposed morbid tissue has been thus removed, the tympanum should be thoroughly syringed. It is often surprising to see the amount of debris that can be further brought away in this manner. 8o Suppuration of the Middle Ear. In a small, indefinite percentage of these cases of chronic otorrhoea, greater or lesser degrees of facial palsy will be evident, probably only sufficient in amount to be found, if the same side of the face as the affected ear be carefully examined, and it is the opinion of the author that this con- dition in its very mild form is more frequent than is com- monly believed. In such cases the palsy is the result of slight pressure on the nerve from serous infiltration of its sheath, as the result of the tympanum being filled with gran- ulation tissue and cholesteatomatous masses, and in such cases this is verified by the removal, as has been described, of the morbid tissue. The disappearance of the slight oblit- eration of the facial lines is within a very short time coincident with the improvement of drainage thus effected. It may usually be premised, as a rule, that when the tym- panum is filled with such material, the antrum is also choked with the epithelial debris, so that in well-marked cases of this nature the removal of the membrana tympani and ossi- cles with the curetting as far as possible of the affected attic, will not cure the purulent discharge, but a complete post- aural mastoid operation should be performed. Again in contraindication to this, the presence of granulation and carious bone in the tympanic cavity does not necessarily imply that the antrum is involved, as occasionally cases are encountered where under such conditions the antrum is apparently healthy, but in the vast majority of cases where the progressive suppuration has resulted in such changes in the tympanum, the antrum and more distant mastoid cells will be found to have undergone considerable morbid alter- ation. During the course of a chronic suppuration, the relief of pain by operative procedures through the canal will oft- times be the only symptom from the view point of the patient that will force him to consent to operation directed towards Treatment of the Mucosa. 81 its relief and at the same time towards the cure of the puru- lent discharge. As specially indicated by the pain of reten- tion, a small perforation in the membrana tympani should be freely enlarged so that the relief obtained is permanent, for if a large opening be not made, the tendency is towards rapid healing with the return of this symptom from the recurring obstruction to free drainage. If the perforation be in Shrapnell's membrane, it should also be fully enlarged and with the small spoon, the margin of the tympanic ring at this point should be removed, providing the external canal be large enough to allow of such manipulations. If relief be not obtained in this manner and the pain is clearly the result of retention of purulent material, either by folds of the mucous membrane, granulation tissue or cholesteatoma- tous masses, these tissues should be removed, including the larger ossicles, which may also be diseased, and all points favoring retention carefully eradicated. In other words, to obtain the successful accomplishment of the two factors just mentioned, all morbid tissue should be removed that prevents in any way the discharge of the purulent material or inhibits free drainage. CHAPTER IV. THE TREATMENT OF THE OSSICLES. THE TREATMENT OF THE OSSICLES. Inasmuch as profound pathological changes in the mu- cosa of the middle ear cavity leaves its destructive impression upon the ossicular chain, certain indications thus become more or less evident, pointing towards the removal of one or more of these bonelets in order to bring about the cessation of the purulent otorrhcea. Before removing the ossicles in any case, with or without excision of part of the attical wall, one should always have given the patient the full benefit of persistent and thorough local antiseptic treatment, and if, in spite of this, the purulent discharge still continues, the question of ossiculectomy should be carefully considered in all its aspects. The indications for removing the remains of the membrana tympani, the larger ossicles and necrosed tissue found in the tympanic cavity, will be found to vary in practically every case, but as a general rule, the operation is usually indicated in chronic otorrhcea when there is a perforation of Shrapnell's membrane with disease of the epitympanum, with definite caries of the malleus or incus, and accompanied with more or less impairment of hearing. When the perforation is in this location, the probe will prac- 85 86 Suppuration of the Middle Ear. tically always find extensive changes in the attic, and as has been pointed out in the previous chapter, it is not only the question of curing the chronic suppuration that is paramount in these cases, but if the affected parts are accessible through the external canal, their removal is essential to protect the life of the individual. As the perforation in this locality, either above or behind the short process of the incus, is the expression of caries of the head of the malleus or incus, the removal of the affected ossicles should be performed even if the attic seems exten- sively diseased, as it will at least delay a more radical opera- tion on the mastoid, and in a number of such cases, the results as regards the otorrhcea will be eminently satisfac- tory, although, on account of morbid changes in the upper tympanic walls, ossiculectomy is of less benefit than when the active site of the disease is located in other portions of the tympanic cavity. Although the operation is indicated when the perforation is marginally situated, the chances of success are much lessened under such circumstances. Often the profuse attical suppuration is maintained by the caries of the incus and malleus in connection with the presence of cholesteatomatous masses, inspissated pus and granulation tissue, while in other cases Shrapnell's membrane may be en- tirely destroyed, the only part remaining being a small rem- nant attached to the malleus, with caries of both the incus and the short process of the former bonelet (see plate XI). Under these circumstances, the indications for the removal of these two ossicles are perfectly clear and ossiculectomy should be performed without unnecessary delay in order that the parts may be freely drained. The presence of a perfora- tion in the posterior superior quadrant of the membrana tympani is a fairly certain sign of ossicular necrosis, and while in some cases the caries of the malleus or incus cannot be accurately recognized even in the presence of granula- The Treatment of the Ossicles. 87 tion tissue, either lower down or in the epitympanum, yet the existence of this perforation is fairly accurate evidence of caries of the incus and usually of its descending process, especially if the perforation extends in a superior or inferior direction. When the perforation in this location is exten- sive, the necrosed portions of the ossicles may be readily felt and their extraction presents no difficulties; in some cases even the head of the stapes may be visible and pus will be observed flowing down from beneath the upper border of the perforation. In these cases it is essential to remove the ossicles, insuring in a moderate number of cases a ces- sation of the suppuration. A further indication for removing the ossicles in the presence of an intractable suppuration, is the existence of a small perforation in other parts of the tympanic membrane than those mentioned, when retention of morbid products is sufficient to make such necessary and where incision has failed to benefit. Marked destruction in any other part of the tympanic membrane in which the suppurative process proves rebellious to constant antiseptic treatment, is also suitable for removal of the malleus and incus. Should the morbid changes be more extensive, one can only hope to obtain a permanent cure by a more radical operation, but in a small proportion of cases, even in the presence of exten- sive tissue changes, ossiculectomy is justifiable should for various reasons a more serious operation wish to be avoided. While the site of the perforation in the membrane will in many cases be sufficient evidence of the area of caries, espe- cially of the ossicles, such is not always to be depended upon, and it seems hardly possible to agree with the observers who claim that it accurately localizes the necrosis, but when pres- ent in Shrapnell's membrane it may give great aid in doubtful cases and in conjunction with other symptoms, will warrant one in performing ossiculectomy in the absence of positive 88 Suppuration of the Middle Ear. signs of mastoid caries. Ossiculectomy is most urgently indicated where the suppuration involves the attic to a great extent, on account of the anatomical relations of this part, as in this immediate vicinity are the incus, head of the mal- leus, the intratympanic muscles and ligaments ; all of which are more or less crowded together, and covered with the numerous reduplications of the mucous membrane, so that unless the intratympanic contents are eviscerated, it is im- possible to obtain free drainage. This is further neces- sary as the swelling of the pus-producing mucosa shuts off various small chambers which become filled with pus and this in turn produces not only ossicular caries, but also necrotic changes in the osseous walls of this region. In such cases both the malleus, incus and the remnants of the mem- brana tympani should be removed, as they are not only in- volved in the pathological changes, but they prevent free access to the parts for the essential cleansing treatment, and while the incus is most frequently carious, yet as a rule the malleus is also to some extent involved. The removal of the ossicles may also be indicated even if the suppuration ceases for short periods of time and again returns, accom- panied with symptoms of retention of confined inflammatory products. This should be done in such cases irrespective of the condition of audition and is more forcibly indicated in the presence of masses of cholesteatoma or such symptoms as headache or frequent attacks of vertigo. Care must be taken to distinguish the two latter symptoms from corre- sponding ones of intracranial origin. In attical disease the removal of the ossicles is indicated in order to curette or cauterize the affected parts which can- not be reached through the canal with these bonelets in situ. Meniere, for this reason, removes the ossicles and cleanses the attic with a caustic solution, such as chloride of zinc, while, when Shrapnell's membrane is perforated and the sup- EXPLANATORY NOTE TO PLATE XII. No. i. Caries of the head of the malleus. No. 2. Destruction of the head and neck of the malleus. No. 3. Caries of the lenticular process of the incus. 90 PLATE XII The Treatment of the Ossicles. 91 purative process is limited to the attic with but little impair- ment of the hearing, it is sometimes better to open the outer attic wall and remove any diseased tissue, as ossiculectomy is apt under such circumstances to seriously compromise the hearing. This can be done, however, in but a limited group of cases, as in the larger majority, as previously mentioned, it is necessary to remove the ossicles to obtain satisfactory results; should the former procedure, however, prove una- vailable in controlling the suppuration, then the ossicles should be removed as a secondary operation, as in the major- ity of attical suppurations ossiculectomy offers the most con- servative and helpful means of curing the patient. In still another and very limited class of cases, where the problem to be solved is to simply prepare a free exit for the escape of pus from the epitympanic space, the removal of the mal- leus, even if it be found free from caries, will be sufficient, but in those cases where the evidence points to a carious process of the walls of the attic and aditus, it will also be essential to remove the incus in addition. Gradingo advises the removal of the malleus or both larger ossicles and destruc- tion by way of the canal of the postero-superior osseous wall. While it is extremely difficult to fix any definite and concise rules for the removal of the ossicles, as this ques- tion must be decided by the merits of each individual case, yet as further suggestions along these lines, one may remove the ossicles if the attic is filled with cholesteatomatous mate- rial, or if the greater portion of the membrana tympani is destroyed, while Barr advocates the removal of the malleus preliminary to opening the antrum. Following the removal of the malleus, it has seemed to be good surgical practice to remove the incus when it shows the presence of caries, or when for any reason, and especially by previous intratym- panic manipulations, this bonelet has been dislodged from its 9 2 Suppuration of the Middle Ear. normal position. As regards the removal of the ossicles where the only conspicuous symptom is more or less puru- lent discharge from the middle ear, opinions vary most mark- edly, but as a rule, one should always hesitate to do an ossicu- lectomy until other measures have been faithfully carried out for a considerable period. It is of interest to note that Whiting advises that in every case where the discharge has persisted for three months or more during the performance of an operation for acute purulent otitis media and mas- toiditis the incus should be removed as a prophylactic meas- ure against chronic suppuration. Ludewig takes the radical stand that after one month of treatment the malleus and incus should be removed irrespective of the presence of caries. It is almost futile to fix any arbitrary period for the performance of ossiculectomy, as any operative pro- cedure will depend entirely upon the peculiar features of the particular case, but speaking broadly, the ossicles should be removed as soon as any of the indications previously men- tioned become marked and then only when the tissue destruc- tion warrants its performance irrespective of the duration of the discharge. They may also be removed when the sup- puration has become intractable in the absence of subjective or objective symptoms pointing to involvement of the pneu- matic spaces of the mastoid process, or it should be resorted to when all other means have failed to control the discharge irrespective of the presence or absence of any of the various indications mentioned. It may in some cases be indicated simply to obtain free drainage even if the tympanic walls are sufficiently diseased to suggest a mastoid operation at some future time, but in which for various reasons such an operation must be indefinitely delayed, or in another class where the carious process is apparently localized to either the malleus or incus. In all cases of chronic suppurative otitis media, conservatism should demand this operation prior to the performance of the mastoid operation. EXPLANATORY NOTE TO PLATE XIII. No. i. Destruction of the long process of the incus. No. 2. Destruction of the long and short processes of the incus. No. 3. Remains of the body of the incus. 94 PLATE XIII The Treatment of the Ossicles. 95 However, in the zeal for more radical operative pro- cedures, ossiculectomy has to some extent been superseded by the various forms of the complete mastoid operation, but such in the author's hands has often proved unnecessary in the absence of definite mastoid symptoms, as the excision of the affected ossicles with the resultant better facilities for treating the other portions of the diseased tympanum, will in a certain percentage of cases cure the suppuration. Many cases are thus susceptible to cure by the performance of ossiculectomy, and while it is not always possible to tell such cases in advance, yet failure in no way compromises a more extensive operation, but rather is but a step towards this end if such be necessary. In the differential diagnosis requisite for eliminating the presence of mastoid alterations in operation through the auditory canal, Barrage and Ciarella have found that the pus from the antrum and mas- toid cells generally follow a definite course in the tympanic cavity and may be distinguished from the pus flowing from the attic or derived from the carious ossicles by its rapid reappearance after cleansing the tympanum, and that it always flows in a straight line over the inner wall of the cavity from the postero-superior to the postero-inferior seg- ment. Thus passing, when the head is held in a vertical position in front of the round and oval windows, while the pus from the attic flows diffusely over the remains of the membrana tympani on its internal aspect. When the pus is principally derived from the ossicles, it is scanty in amount and reappears so slowly that its source is readily distin- guished. This phenomenon has proven of value in selecting the form of operation in several obscure cases and based on this sign the authors quoted were able in six cases to confirm its diagnostic value by operation, finding a mastoid empyema in each case. When isolated caries of the ossicles can be recognized and it is of such a degree that medicinal meas- 96 Suppuration of the Middle Ear. ures will apparently prove futile, the bonelets should always be removed, but when in the presence of an intractable sup- puration such is doubtful, the removal of the bones through the canal will at least lessen the dangers of pus retention. Should caries of the antrum be found associated with cho- lesteatomata, the removal of the ossicles through the canal can be of but little or no service, and in such cases it has seemed better to do the radical operation, as in this way only can all the diseased tissues be reached and removed. In summing up the somewhat numerous indications for removing the ossicles, the classification, as given by Politzer, most clearly and concisely outlines the various classes in which this procedure is necessary, the following being the special indications: (i) In suppuration resisting treatment with caries of the malleus. (2) Obstruction to the flow of pus from the superior tympanic space, and when in spite of treatment, it is occasionally accompanied with partial swell- ing of the postero-superior wall of the meatus. In this class are those cases where the handle of the malleus is adherent to the promontory wall and in which there is a fistula in the postero-superior quadrant of the membrana tympani, through which flows curdy, septic secretion from the attic. (3) Cholesteatoma in the superior tympanic space, causing frequent relapses of the suppuration. (4) Obsti- nate suppuration of the external attic, with perforation of Shrapnell's membrane, and in such cases even if no caries of the malleus and incus be found, always remove the ossicles if the larger portion of the membrana tympani is destroyed and only a small remnant is connected with the malleus. (5) Granulations in the attic, recurring and growing into the tympanic cavity and meatus, especially if pus retention be also present, but in this class the cure is rarely permanent, and in the large majority of such cases the radical operation has to be performed sooner or later to obtain a lasting result. The Treatment of the Ossicles. 97 Naturally, ossiculectomy presents certain limitations, as a certain proportion of chronic suppurative cases cannot be relieved by this measure, but require more extensive removal of the largely diseased areas. Facial paralysis resulting from operation through the canal but rarely occurs. As regards the limitations of ossiculectomy, one can expect it to be of great value when properly performed in selected cases, but it should not be done simply on account of the presence of an aural discharge, for if this should be very mild or unirritating and has had no apparent effect upon the hearing, topical applications directed to the mucosa of the tympanum will result in a cessation of the discharge. One may roughly, yet quite satisfactorily, divide cases of chronic suppuration into three classes : firstly, those in which the sup- puration is the result of carious changes of the ossicles and in which the bonelets should be removed. Secondly, cases in which the predominating feature is the change occurring in the walls of the tympanum, when ossiculectomy may or may not be performed, the determining factor being the degree of the bone involvement and its extension into the antral cavity or not. While the third class positively pro- hibits evisceration in this manner, as it comprises that group in which the purulent discharge is the consequence of morbid changes in the antrum and mastoid cells and the removal of the ossicles alone will in no way limit the course of the disease, but may be performed previously to the radical oper- ation in order to temporarily aid free drainage, when both malleus and incus should be removed. Caries and necrosis, as related to the surgical treatment of this condition, may be limited to the ossicles alone, or, as is more frequent, may also involve the adjacent bony walls to a greater or lesser extent. It may still further be limited to the malleus alone, or again the incus only may be involved in the destructive process and in some cases, although it is 98 Suppuration of the Middle Ear. not commonly found, the entire ossicular chain may be carious. The knowledge of the parts involved in the carious changes is important, as upon it depends the form of opera- tion employed to relieve the chronic aural suppuration, and while the body of the incus, in connection with the head of the malleus, are most frequently involved, yet when but one bonelet is affected, the incus, as will be mentioned later, is the one usually involved, the stapes rarely being affected to any degree unless in connection with well-marked necrotic changes of the other ossicles and usually of the bony walls. When both the larger ossicles are involved, the carious process commonly originates at the malleo-incudal articu- lation and extending deeply into the bony structures of these ossicles, until, in severe cases, only an irregular minute piece of bone, representing the fused malleus and incus, may be found, usually embedded in a mass of granulation tissue (see plates XII and XIII). Again, the head of the malleus may be totally destroyed and the handle, if found at all, presents the appearance of terminating abruptly above the short process. As long as the manubrium is protected, even by a remnant of the membrana tympani, it usually remains intact, but when this also becomes destroyed and the suppu- rative inflammation extends to the periosteal layer, this osseous process gradually undergoes absorption and may entirely disappear. As a rule, in these cases, the lower part of the manubrium alone is completely disintegrated, although the upper portion may feel rough to the probe, but it is quite uncommon to observe the manubrium so completely destroyed that only the short process and the head of the malleus remain. While, as before noted, the incus is more frequently involved than the other ossicles, the long process is destroyed more often than the other anatomical divisions of this bone, and it may be simply eroded by the absorption produced by the constant passage of irritating pus flowing over it, or, The Treatment of the Ossicles. 99 again, as is more frequent, this process may be entirely de- stroyed by caries. The stapes, from its more or less pro- tected position, is but rarely involved, and from its resistance to the carious process, which it seems to possess to a remark- able degree, it is usually found to be intact, although the capitellum and one or both crura in part may be destroyed and only the foot plate will be found remaining in the oval window. Coincident with or previous to the destruction of the ossi- cles in part or whole, the continued suppuration may pro- duce loosening or complete separation of their various artic- ular attachments, either by the absorption of their ligaments or by a more rapid destruction which especially occurs in cachectic individuals. This displacement of the malleus and incus particularly may also result from direct pressure ex- erted upon them by masses of granulation tissue, or it may also occur when the surfaces of the bone in relation to the articulations becomes necrotic and granulation tissue, spring- ing from these areas, erodes and penetrates directly into the delicate joints. The joint most frequently affected in this manner during the course of a chronic suppuration is that between the incus and stapes, and this change so frequently encountered in the surgical treatment of this condition exer- cises a most important bearing upon the modifications neces- sary in performing ossiculectomy in such cases. When the articulation between the malleus and incus has been de- stroyed, the latter ossicle immediately loses its topograph- ical position in the tympanum, and it may either be pushed into the antrum, where it is practically inaccessible by opera- tion through the canal, or it is often discharged from the canal during cleansing of the ear, so that unless this con- dition be recognized much time will be lost in searching for it, when only the malleus and stapes remain. The malleus also changes its position when a separation of this joint ioo Suppuration of the Middle Ear. occurs and it usually swings about on its axis, so that it is retained in this altered position by the tendon of the tensor tympani muscle, or by its anterior ligament, or both, although the latter, in cases of this severity, may also in great part be destroyed. In extreme cases, especially when a tuber- cular element is present or the degree of caries and necrosis is such that operation through the canal is contraindicated, the ligamentous tissue supporting the foot plate of the stapes in the oval window may also be destroyed and the stapes may be entirely displaced spontaneously, or the slightest touch with the probe will be sufficient to dislodge it. In such cases, the various intratympanic ligaments, muscles and redupli- cations of the mucosa are also in great part destroyed, so that the ossicles have either become entirely obliterated or have been washed away in the profuse purulent discharge, and of course in such cases the radical mastoid operation is the only measure which holds out the best chance of a per- manent cure of the suppuration. As the malleus and incus, with their articulation, are so often carious, it is somewhat difficult to always obtain satis- factory evidence of the presence of disintegrating changes in these bones, but if there is a defect in the anterior wall of the attic, or a perforation in Shrapnell's membrane, the probe passed through either of these may be able to detect roughened bone unless the caries is located on the internal aspect of these ossicles, where, of course, it is inaccessible. In many cases the diagnosis previous to ossiculectomy cannot be definitely proven, but the symptoms of persistent sup- puration with a perforation in the posterior segment of the membrana tympani, as before described, is strong evidence of caries in this situation, and if, in addition to this, puru- lent or cheesy material is found coming from the attic and granulation tissue in this region rapidly recurs after removal, one is absolutely justified in considering that caries is pres- ent and in removing both the larger ossicles. As has been The Treatment of the Ossicles. 101 pointed out by several observers, the ossicles, as regards the presence of caries and necrosis, bear a marked similarity to the long bones of other portions of the body, as their articular extremities, similar to the epiphyses of the long bones, are most often and primarily involved in the carious process, while their more slender processes are much more frequently affected by the necrotic process, as is also the diaphysis of long bones. In regard to the relative frequency of the involvement of the parts in these destructive processes, the handle of the malleus and the short process of the incus most frequently show necrotic changes, and while these parts are at first being more or less gradually disintegrated, the articular surfaces of both the larger ossicles may show but a very scant loss of osseous tissue or may for a considerable time at least present no evidence at all of necrotic change. As the result of the various pathological changes which take place in the tympanic cavity and so markedly alter the relations of its contents, the technique of ossiculectomy must vary almost in every case to suit the particular conditions present. Granulation tissue, epithelial masses and inspis- sated purulent material may fill the cavity so that all the landmarks are abolished and even the ossicles, as previously mentioned, may be absent, from destruction, or be repre- sented only by an irregular necrotic fragment (see plate XI). In other cases calcification has taken place, so that consider- able force is essential in their removal, while again, adhesions between the malleus and incus and the tympanic walls is somewhat frequently encountered, so that it is extremely difficult to even locate the irregular bony masses representing the ossicles in order to successfully remove them. It is nec- essary, therefore, in describing the various methods for their removal, to explain the operation as if the ossicles were in their normal positions with their articulations intact, and then as far as possible make clear the various modifications essentially concerned in their altered condition. 102 Suppuration of the Middle Ear. In performing ossiculectomy, anaesthesia, either local or general, is always essential ; the choice of anaesthetic depend- ing entirely upon the amount of tissue to be removed and the extent of damage to the osseous walls of the tympanic cavity. When the membrana tympani is in great part de- stroyed, so that free ingress to the parts may be obtained, the canal of ample size and the patient well under control, with but a few bone fragments or possibly the malleus and incus to be removed without the walls requiring extensive curetting, local anaesthesia with cocaine in from 5 to 20 per cent, solution will be most satisfactory. As the various fresh areas of tissue are exposed, they must be cocainized, as it is essential that no pain be inflicted, as the head of the patient must be held absolutely immobile, and if there is much nervousness, general anaesthesia will have to be em- ployed. The cocaine may be used in conjunction with adrenalin chloride, so that bleeding is reduced to the mini- mum amount. The head of the patient is inclined and the canal of the ear filled with a I to 1000 adrenalin solution; this is allowed to remain for about five minutes, when the parts will become blanched, then the cocaine solution of the strength desired is used in the same manner and allowed to remain about fifteen minutes, when the parts are dried and both the solutions again applied in the order noted, when, after thorough drying, the parts are ready for operation. As one is never sure of the amount of tissue destruction, or if dangerous areas may be exposed until the operation is well under way, and as it is a serious problem in curetting a mass of granulation tissue under cocaine anaesthesia to find that their removal has exposed the dura through a cleft in the tegmen tympani, it is better in the majority of cases where granulation tissue, cholesteatoma masses and evi- dences of extensive caries are present, to use a general anaes- thetic, as the patient can be better kept under the absolute The Treatment of the Ossicles. 103 control of the operator. The question of anaesthesia must of necessity be separately decided in each individual case that comes to operation, and while local anaesthesia is always preferable as a general principle if the conditions allow, yet general narcosis must be employed in the larger number of cases operated upon. Nitrous oxide has been employed for this purpose in some instances, and while with its use one can have the patient in an upright position, which is a great desideratum, and possessing as it does the advantages of rapidity of anaesthesia, rapid recovery without nausea fol- lowing its administration and the practical elimination of danger, yet its effects are too transitory. The posture of the patient should be such that the posi- tion of the membrana tympani be kept as nearly normal as possible in relation to the natural position of the patient's head when in an upright position, so that the normal topog- raphy of the parts will be maintained, the ideal position of the patient being the upright posture, with the head firmly fixed in position. With local anaesthesia this, of course, is always possible, but the reverse is the case under general narcosis, and when a general anaesthetic is employed, the patient of necessity being in the recumbent position, the shoulders should be elevated so that the head can be turned in any direction desired. Upon no point does the success of ossiculectomy depend so much as upon proper illumina- tion, as it is absolutely impossible and extremely dangerous to attempt to remove the ossicles unless the parts are well illuminated, so that every step of the operation can be seen. With local anaesthesia the head mirror and gas illumination may be employed, but when general narcosis is employed, this is impossible and the electric head light should be used. This is the more satisfactory, however, irrespective of the anaesthetic or posture of the patient, and with a good photo- phore it is perfectly possible to observe just what is being 104 Suppuration of the Middle Ear. done during all the steps of the operation, as the light can be focussed to the point desired, the rays falling in a direct line. As essential as any other factor in obtaining successful results in ossiculectomy, is the method adopted for the con- trolling of the bleeding which necessarily ensues when in- cisions are made into the softer tissues and especially when granulation tissue is removed. Adrenalin chloride is par excellence the most satisfactory haemostatic that we possess, and when applied as indicated, with in addition its free use during the entire course of the operation, it will in the ma- jority of cases render the operation practically bloodless and remove, to a great extent, the rapid filling of the tym- panum with blood after the first few incisions have been made, and which, previous to its introduction, forced the operator to an undue haste and kept him constantly mopping the blood away with cotton tufts. Thus, when freely used, it both simplifies and shortens ossiculectomy by reducing the bleeding to a minimum and at the same time allows one a greater space for the various manipulations by its marked action in shrinking the tissues. The effect of the cocaine anaesthesia seems as well to be intensified by the combina- tion with adrenalin. The hemorrhage may also be con- trolled by packing the tympanum and canal with small strips of iodoform or sterile gauze, either dry or soaked in adrena- lin solution. A semirecumbent position of the patient aids to some slight extent in preventing excessive bleeding. The strips of gauze should be carried well into the tympanic cav- ity and firmly pressed against the bleeding areas if such be visible, a large number of small pieces being used in pref- erence to one or more larger ones. That the bleeding may even in the hands of an experienced operator be of sufficient severity to interfere with the operation has been shown by Schmiegelow, who, in a case where he was endeavoring to remove the malleus, encountered such severe and obstinate bleeding that he was forced to desist from operation. The Treatment of the Ossicles. 105 The necessary instruments most frequently employed consist of a speculum, and it is essential that the largest that will comfortably fit the canal should be used for this pur- pose, a number of applicators, previously wound with sterile cotton, delicate forceps and a snare, the two latter being to seize the ossicles after their attachments have been severed and remove them from the tympanic cavity. The knives used for this purpose should be both sharp- and probe- pointed, curved and straight, and small angular knives with the sharp edge bent close to the point both at an obtuse and at a right angle. The knives recommended for this purpose by Bench are quite satisfactory. They are made from small steel wire and the shaft of each knife screws into a small handle, it being advisable to have each instrument with its handle attached rather than a universal handle. The shank of the knife is malleable, so that it can be bent at any angle desired, yet has sufficient firmness not to bend when cutting through the tympanic tissues. The question as to whether the shaft of the knife is straight or forms an angle with the handle bears no relation to its value for the purposes men- tioned, as the selection of. a matter of this nature depends entirely upon the personal taste of the operator, although, as a rule, the straight handled knives are more readily man- aged and do not get in the visual field as one would com- monly suppose. It is also necessary to have various small sizes of curved and blunt hooks and also sharp hooks, while straight and angular sharp spoons are also essential. When removing the anterior attic wall cutting forceps or chisels are necessary and for cleaning out this part various curettes may be used, Lake's being quite valuable for this purpose. It is crochet-shaped and by its use small particles of the necrotic ossicles, and especially the incus, can be readily removed. As advised by its originator, it is passed into the attic after the malleus has been removed and there occupies io6 Suppuration of the Middle Ear. the place made vacant by the head of this bone, the handle is then rotated forward and grasps the incus or any rem- nants that may be found and by a forward and downward motion, the bone is dislodged into the tympanum or removed entirely in the loop of the instrument. It is unnecessary to give a detailed description of these various instruments, as they can be obtained in various forms and in describing in detail the removal of the separate ossicles, the use of the various instruments will also be described. The first step necessary to the removal of the ossicles is the dissecting away of the remnants of the membrana tympani, and this may be done by one of several methods, depending upon the conditions present. If a large remnant of this membrane remains, it is incised near its periphery with a straight narrow knife which may be pointed or rounded at its end, and as far as possible the incision should be placed in close connection with the tympanic ring, while the membrane should be entirely removed. When adhesions are present between the membrana tympani and the walls of the cavity, they should be dissected away with straight or angular knives, as may be necessary in the individual case, and with a straight knife the membrane is incised around its entire periphery about a line from its attachment to the annulus tympanicus. This leaves it free in all respects ex- cept its central attachment to the manubrium and this is removed by using the same knife and continuing the incisions down on each side of the malleus, where they meet at its tip, and thus completely sever the membrane from all its attachments, when it is then removed with forceps. This must be modified by omitting the incisions along the manu- brium and lower arc of the circumference of the annulus in those cases where the inferior two-thirds of the membrana tympani has been entirely destroyed, and where the remains of Shrapnell's membrane is hyperplastic and the seat of an The Treatment of the Ossicles. 107 increased vascular supply, so that it appears to be firmly in contact with the ossicles and seems to render them invisible. Under these circumstances the landmarks may be entirely obliterated or the short process of the malleus and the promi- nent foreshortened horizontally lying portion of the manu- brium may be seen, the tip of the latter often having formed an adhesion with the superior portion of the internal tym- panic wall. In other cases in which the membrane has previously been apparently destroyed, one may find only a thin cicatricial membrane, especially in the superior seg- ment, which reveals through it the articulation of the incus and stapes if it has not already been destroyed, which is not at all uncommon in such cases (see plate VIII, Fig. 2). This membrane must be dissected away by the peripheral incision, and if it be found impossible to remove it from its attachment to the malleus, it should be allowed to remain until this ossicle is removed, when it will come away at the same time. When only a small area of the tympanic membrane has been de- stroyed, the peripheral attachments of the membrane may be cut from below upwards by introducing the knife through the perforation and commencing the incision from this point. This, however, cannot be well done if firm adhesions exist between the membrane and the tympanic wall, but if these are not present, and such is the case in a few instances, this method is very serviceable. Should numerous adhesions be present they may cause excessive annoyance by their bleed- ing when severed ; it is far more advisable to incise the supe- rior segment of the membrana at first, and instead of com- mencing at the perforation, anterior and posterior incisions are made from above, both of which are continued into the perforation. Again, the remnants of the membrane may be removed by entirely ignoring the perforation present and inserting a straight-pointed knife into it immediately above the short io8 Suppuration of the Middle Ear. process. From this point the incision is made backwards, dividing the membrane as closely as possible to the tympanic ring, care being taken at the same time that the knife is inserted not too deeply into the tympanic cavity in order not to damage the ossicles or their articulations. The anterior attachments of the tympanic membrane are then incised in the same manner and it will be found that in this way bleed- ing has been reduced to a minimum and the malleus can be readily removed. In whatever method is adopted in the individual case, it should always be endeavored to remove as much of the membrane as possible, as it is apt to cover a necrosed area at the margin of the tympanum, and if any membrane be left, this carious spot is very apt to remain undiscovered, although there may be a single exception to this, and that is in cases where the extreme lower part of the membrane is healthy and the probe shows that the osseous tissue in its immediate vicinity is also sound, then a small portion may be allowed to remain in this situation in order that it may act as a basis for the epidermization of the tym- panic cavity, so necessary to the complete cure of the sup- puration. While evidence of caries of the malleus is plainly obtain- able in the vast majority of cases in which this ossicle is diseased when the perforation embraces the larger portion of the tympanic membrane, yet in those cases where Shrap- nell's membrane alone is the seat of a perforation, one can not be always sure of the involvement of the malleus, although the probable presence of caries may be fairly well surmised under these conditions if the discharge seems to be excessive in this region and escapes through the perfora- tion in this location. The studies of Ferreri are of impor- tance in this connection, as he found in thirty-eight cases of chronic tympanic suppuration that the lesions of the mal- leus and incus were very slight and in the main consisting EXPLANATORY NOTE TO PLATE XIV. A schematic drawing demonstrating the removal of the malleus, with the forceps m position. The upper lateral wall of the tympanum showing areas of necrosis. no PLATE XIV The Treatment of the Ossicles. 1 1 1 of an atrophic process, as shown by the rarefaction of the bony tissue and a diminution in volume of part or all of the ossicle, while in several of the cases the atrophied bone was surrounded by granulation tissue. In another series of thirty-seven cases, it was found in twenty-three that there were circumscribed or diffuse caries, and as a rule the carious ossicles were surrounded with masses of granulations. The carious area sometimes involved one of the articular sur- faces and then produced ankylosis between the malleus and incus, and in every instance where the lesion of the ossicle was in any way serious, it was always secondary to a diffu- sion of the inflammation which had primarily attacked the mucosa of the tympanic cavity. Previous to the removal of the malleus the tensor tym- pani muscle must be severed at its attachment to the ossicle, and this is best performed by means of a delicate sickle- shaped knife or one shaped like a small spade, bent at an angle with the shaft. The end of the knife is carried under the anterior or posterior fold as may be most convenient in the particular case, when depending upon its position in relation to the malleus, it is gently rotated forward or back- ward posterior to the bonelet, until the tendon of the muscle is recognized by the knife coming into contact with it, when, by a slight sawing motion, the muscle is severed from its attachment to the bone. Schwartze's tenotome is also most satisfactorily used for this same purpose by gently inserting it into the tympanum and towards the tegmen; the cutting edge is then inclined forward until the position of the head of the malleus is plainly ascertained, when, with a slight for- ward rotation the knife engages the tendon of the muscle, which is then severed, as before directed. As the tendon is cut through, one can readily feel the consequent lack of resistance and if the parts are illuminated as they should be, the manubrium will be seen to move in an outward direc- ii2 Suppuration of the Middle Ear. tion. At one time tenotomy of the tendon of the tensor tympani muscle was recommended as an independent pro- cedure in the treatment of chronic otorrhcea, as it was sup- posed to aid drainage and have some beneficial effect upon the hearing, and while it may be done when evidences of caries of the ossicles are absent with the perforation situated in the lower segment of the membrana tympani, yet it is absolutely useless and should only be performed as one of the initial steps in removing the ossicles. In those cases where the perforation is around the manubrium or situated still higher up, with caries of one or both of the ossicles, this procedure, if performed with the idea of helping the patient, is valueless, as such cases only can be relieved by removing the remnants of the tympanic membrane and excising the malleus and incus. Where there is much destruction of tissue and the malleo- incudal articulation has been opened the prominent short process may or may not be seen. The parts are then exam- ined for the somewhat frequent adhesion of the manubrium to the promontory, and if this is not found but the ossicle be free, it is grasped with forceps, preferably just below the short process, and readily extracted ( see plate XIV). When, however, adhesions exist, it is best to pass an angular knife from above downwards along the internal surface of the manubrium and cut any bands which may tie the bone down in this location, or if the adhesions are firm and the malleus seems almost immovable, one should carefully avoid using any force and the adhesions connecting the bone to the promontory should be divided with a small knife curved on the flat which will then usually release the bonelet, but should it still remain fixed, one should cautiously endeavor to find the cause of its binding down with a fine probe, and when the adhesions are located, a suitable knife should be used to divide them. In other cases, when the major part of the The Treatment of the Ossicles. 113 membrana tympani has been destroyed, but the incudo- stapedial articulation remains intact, this may be first sev- ered and the malleus then removed, but this is rarely neces- sary. When the manubrium is carious or has became rare- fied, it is very apt to break as soon as grasped by the forceps in attempting to withdraw the malleus, so it is always advisable to grasp the ossicle higher up, and drawing it slightly inward, so as to release its neck from its insertion into the notch of Rivinius, it is then brought downward and easily extracted from the canal; various forceps may be used for this purpose, as alligator forceps, Sexton's, Hart- mann's, etc. Again, gentle traction or a slight rotary mo- tion of the ossicle grasped in the forceps from side to side may be made, until it is thus brought into the lower part of the tympanic cavity on a level with the canal, when it is turned to one side and so extracted. In some cases, where the malleus presents but little apparent alteration, its connec- tion with the margin of bone above should not be interfered with until it has been entirely separated from its natural attachments and the incudo-stapedial articulation has been severed, so that the manubrium retains its natural position and does not move out of place. It frequently occurs that the destruction has been so great that a greater portion of the incus is necrotic and has become entirely detached from the malleus. Under these conditions the removing of the latter bonelet is very simple, as it only is necessary to grasp with forceps and lift it out of the tympanic cavity where it lies practically as a foreign body, being free from its membranous attachments. When this ossicle is firmly attached superiorly to the margo tympanicus and Rivinian segment, several semicircular incisions in this region with a straight-pointed knife will usually suffice to loosen it and it may be removed with the loop of a snare or seized by forceps at its neck and then drawn down until it 9 ii4 ' Suppuration of the Middle Ear. can be extracted. When adhesions firmly hold the malleus to the incus, great difficulty may be experienced in its ex- traction, as this may be composed of a purely connective tissue growth, or the union between the two ossicles may con- sist of a true ankylosis and in such cases when the manu- brium is caught in the forceps it is very apt to break off and the body of the malleus remains attached to the incus in the epitympanum. The breaking of the bonelet in this manner is due primarily to the weakening of its structure from absorption of osseous tissue or the using of too much force in its extraction. Another method of removing the malleus, which is appli- cable when the bone is freely exposed, is by the use of an oval ring knife of which several varieties may be obtained, that of Delstanche being quite satisfactory. The ring with the blade is placed at an angle to the handle, so that the cut- ting edge is directed upwards and by placing this around the malleus it is pushed from below upwards so that it severs the tendon of the tensor tympani muscle, and then, by gently rotating it outwards, the malleus is so brought down that it can be removed with forceps. As a final method of removing the malleus that described by Dench is extremely satisfactory : " The stapes tendon is first divided, then the incudo-stapedial articulation is severed and with a pointed knife Shrapnell's membrane and the ligaments binding the malleus anteriorly and posteriorly are severed, the knife is then held so that the flat surface of the blade is directed towards the roof of the canal and the edge backwards, so that the point, entering just above the short process of the malleus, is pushed inward and upward and the handle is depressed. In this way the knife enters the fornix of the tympanum and cuts its way outwards, downwards and back- wards, thus severing the external and posterior ligaments of the malleus and dividing Shrapnell's membrane posteriorly. EXPLANATORY NOTE TO PLATE XV. A schematic drawing demonstrating the removal of the incus, after the com- pletion of the removal of the malleus. An angular knife in position cutting through the suspensory ligament of the incus. 116 PLATE XV The Treatment of the Ossicles. 117 The knife is then reversed and cuts in the opposite direc- tion, is carried forward over the short process and divides the anterior segment of the membrane, some fibers of the external ligament and the anterior ligament of the malleus. As the bonelet is now only held in place by the weak supe- rior ligament and the tendon of the tensor tympani muscle, it is grasped with suitable forceps just below the short process and extracted by pressing inwards to dislodge the neck of the bone from the projection upon which it rests, and this is followed by traction downwards, then outwards" (Dench). Following the removal of the malleus, the next step in the operation should be the extraction of the incus, as it is more frequently involved in the carious process than any other ossicle. Schroeder in one hundred and thirty operations of this nature, which he considers as the only sure means of benefiting attical suppuration and which he states should always precede any form of radical operation on the mas- toid, found caries of the incus in 88 per cent, of his cases, while in 41 per cent, of these the malleus was found to be normal, and for this reason it is highly important that the incus should be removed after extracting the malleus. Lude- wig found it carious in 85 per cent. ; in twenty-nine cases of Bench's it was carious in nineteen, while in eight of these it was completely destroyed. This peculiar susceptibility of the incus to be involved to such an extent in the carious process is readily seen by an examination of its blood supply and topographical relations, as the vascular supply is ex- tremely limited, being derived only from the minute petrosal branch of the stylo-mastoid artery, which from its super- ficial position in the upper tympanic space is easily com- pressed by any swelling of the mucous membrane which takes place in this region, it being the rule that when the ossicular chain is involved in the carious process the incus is affected not only first but also to the greatest extent. On account ii8 Suppuration of the Middle Ear. of its position and the delicacy of its supporting ligaments, the suppurative process in the epitympanum from an early stage directly involves this bonelet, its peculiar shape espe- cially predisposing it to the full destructive action of the purulent secretions. Undoubtedly its scanty vascular sup- ply is by far the main feature concerned in this process, but at the same time the other factors mentioned play an impor- tant role as contributing causes. The most common spot on the ossicle which seems to apparently be primarily in- volved by the caries is its long process near the body, or the body itself may be in great part destroyed, so that its posterior portions remain intact and its partially carious long process articulate to the stapes ; the frequency in which this joint becomes involved being illustrated by Green's cases, in which this took place in 75 per cent. Should the incudo-stapedial joint, however, still remain intact, it must first be severed before the incus can be re- moved. This may be done by the use of a small sharp- pointed knife placed at nearly a right angle with the shaft and an incision is made through the articulation as near as possible, perpendicular to the axis of the stapes. As soon as the joint has been divided the added movement given to the long process of the incus will indicate that this measure has been successful in those cases where the incus is placed high up on the wall of the tympanum, while where it is situated more inferiorly, the entire procedure can be readily seen. The articulation may also be severed by placing the knife behind the long process of the incus and by cutting forward and downward the action is more or less resisted by the stapedius muscle, and any damage to the stapes is in this way reduced to a minimum and the division of the articulation is more easily performed. The long arm of the incus should be used as the main landmark in performing this part of the operation and after the joint has been sev- The Treatment of the Ossicles. 119 ered by any of the various methods here described it is always advisable to insert the point of the knife below and draw it upwards, to sever any undivided ligaments of the capsule that may still remain; the knife may also for this purpose be drawn as far as possible around the long process of the incus, at the same time cutting downwards. Many operators consider it advisable to cut the tendon of the sta- pedius muscle before attacking this articulation, as it is claimed by this procedure that the parts can be more per- fectly seen; the method of doing this therefore will be con- sidered later in connection with the operative procedures upon the stapes. When it is difficult to insert the knife between the annulus tympanicus and the long process of the incus to sever this articulation, the procedure recom- mended by Bench may be satisfactorily adopted by passing the cutting instrument in front of the long arm of the incus and open the articulation by cutting downwards and back- wards, as it may be severed from its lower aspect by cutting through it backwards and forwards. After this articulation has been severed, the incus may be removed by any one of several methods, depending whether it has remained in its usual situation or has altered its position. A few otologists remove the incus previous to excising the malleus on account of the supposed danger of the former becoming dislodged into the posterior inferior part of the tympanic cavity, where it is extremely difficult of access. But this method is not to be recommended as it is generally impracticable, and where the suppuration has been extensive only a small remnant of the incus will be found after the malleus has been removed, the former being dis- lodged from its position in the attic and brought forwards and downwards into the tympanic cavity, when it can be removed. It should be remembered that in a certain pro- portion of cases the greater part of the incus has been de- 120 Suppuration of the Middle Ear. stroyed, and what remains of its body is fused to the malleus, so that when the latter is removed the incus is carried away with it, a careful examination of the former being always advisable before search is made for a supposedly missing incus. While the. extraction of the incus is much more difficult than the removal of the malleus, yet in practically all cases both the ossicles should be removed inasmuch as already shown the former being more frequently carious, if allowed to remain keeps up the suppurative process. As a further necessity for removing the incus, its function is of course lost when the hammer has been removed and it is most advisable under all circumstances to remove it or its necrosed remnants with the various hooks used for this pur- pose. In some cases the procedures mentioned will allow the incus or at least its long process to be seen and then by drawing it downward, forward and outward no difficulty at all is encountered in its removal; on the other hand, it is often displaced downward and is closely associated with the border of the tympanic ring, so that its long process espe- cially appears to be a part of the annulus and in not a few instances one will have to carefully differentiate one bony process from the other by using the probe, so that when the incus is recognized it can most usually be lifted away with the forceps, or more rarely it will have to be slightly moved from this position before it can be securely grasped by the forceps or a right-angle blunt spoon with its concavity di- rected backwards, which is very useful for this particular purpose. In a considerable number of cases of chronic otorrhcea, after one has removed the malleus, no trace can be seen of the incus, and it then becomes necessary to carefully search for it until it has been found, or positive evidence is ob- tained that it is not present. In such cases various methods may be employed to remove the remnants of this ossicle de- EXPLANATORY NOTE TO PLATE XVI. A schematic side view of the tympanum showing necrosis of the handle of the malleus and a polypus protruding through the drum membrane. i, Polypoid excrescence; 2, drum membrane; 3, necrosis of the handle of the malleus ; 4, external auditory canal. 122 PLATE XVI The Treatment of the Ossicles. 123 pending upon its supposed location, various forms of incus hooks being used to bring its long process into view. These hooks are curved so that one is available for the right, the other for the left ear, and in using them one should guard against the hook catching in the process of bone over the antral entrance in endeavoring to search for this ossicle, as this accident is apt to happen if the hook be made too long. The incus hook for the side to be operated on is pushed into the cavum tympani and its angular portion is inserted well behind the tympanic ring in the position of the missing incus, when it is slightly rotated forward and at the same time carried upward, so that it will swing the long arm of the bone into the field of vision. Alderton for this purpose uses Ludewig's incus hooks, or a right-angle spoon carried up in a vertical position behind the pars epitympanica and as far forwards as possible until the shank touches the bone; it is then carried backwards, maintaining it close to the inner surface of the pars until it occupies the normal situation of the incus, when the tip is rotated backwards towards the aditus until the incus is engaged, when it is brought into view by traction downwards. If these procedures should fail as a result of the incus lying in a lower position, or is in part in very close contact with the tympanic ring, one may adopt the procedure used by Bench of entering the hook at the antero-inf erior portion of the tympanum with its con- cavity directed posteriorly, and by rotating and sweeping backwards and upwards the extremity which touches the tympanic ring, the incus will be brought into view if it is in the antero-inferior part of the tympanum. If it should not be found here, however, the hook should be directed upwards and forwards through the posterior and superior parts of the tympanic cavity, and at the same time keeping it pressed firmly against the internal margin of the tym- panic ring. Care should be exercised in performing this 124 Suppuration of the Middle Ear. manoeuvre that the stapes is not damaged. Should this not bring the incus into view, use the hook designed for the oppo- site ear and carry it into the fornix tympani with the con- cavity directed backwards and its angular portion hooked behind the inner extremity of the superior wall of the exter- nal auditory canal, when it is rotated backwards and carried downwards and usually this procedure will bring the bonelet into view where its posterior ligament is unduly strong or its long process has rotated too far backwards out of reach of the hook. This method should, however, only be used as a last resort, as, if used at first, it is very apt to displace the incus into the antrum, where it is impossible to recover it by way of the canal. Kretchmann, in removing this ossicle, uses a curved hook which is so bent at its distal extremity that its tip will rest on the osseous shelf of the superior wall of the canal which affords a lodgment for the incus. By this method the hook is introduced with its concavity back- wards and brings the incus into view by rotation backwards with moderate traction downwards, the objectional feature of this method, however, being that one is very apt to dis- place the bonelet into the antrum, although the danger of doing this may be avoided to some extent by entering the hook posterior to the long process providing such be visible and rotating it forwards. In a few cases, where the incus is not seen, it may in great part be covered by the membrane which has not been incised close enough to the tympanic ring, or the destruction of the osseous part of the annulus at this point may render its recognition almost impossible, especially if the incus be adherent to these parts. Under these conditions it is necessary to remove the soft parts to ascertain if it be present, and if it be not found, even after performing the various procedures previously indicated, one may be fairly sure that it has either been pushed back into the antrum or destroyed by the suppurative process. The Treatment of the Ossicles. 125 When only a portion of the incus remains and this is usually its body which is frequently calcified and adherent to adjacent tissues, Ludewig's hooks are more satisfactory for its removal than any other form of instrument. With such a condition present, the hook is directed towards the antero-superior part of the attic and with its concave sur- face directed backwards it is moved in a posterior direction so as to engage the remnants of this ossicle. When the attic seems to be unusually capacious, this procedure should be repeated several times, so that the entire attical space is ex- plored and the incus engaged, but great care should be exer- cised when passing the instrument along the median wall to avoid the facial canal, as the nerve is undoubtedly in danger at this point (see plate I). If this procedure should prove to be futile, however, it may in some cases be reversed with successful results, the incus hook being swept from behind forwards and thus removing the ossicle in this manner. Ludewig's method of removal of the incus, necessitates the preliminary excision of the malleus and the severing of the incudo-stapedial articulation. The incus hook is introduced into the upper tympanic space beneath the segment of Rivin- ius and its point is turned upwards ; the hook is then turned backwards and rotated in a semi-circular manner down- wards, so that the point of the hook grasps the incus at its saddle-shaped facet and dislodges it into the lower tympanic space, where it is removed either by syringing or preferably by forceps. The method advocated by Zeroni may finally be mentioned in this connection, although it is not as suc- cessful in its application as some of the other methods here described. Instead of the usual incus hook, an eyelet is employed by introducing it into the posterior part of the tympanic cavity and carrying it along the medial wall from below upwards, it is slightly drawn towards the external attic wall and grasps the incus when the latter is drawn into view by a slight downward pull. i26 Suppuration of the Middle Ear. Various untoward symptoms or accidents are liable to take place during attempted removal of this ossicle, such as pain in the head, vomiting and vertigo, the latter being especially frequent when the patient is conscious and local anaesthesia alone is being used; however, these symptoms are usually of but transient duration, with the exception of the vertigo, which may last for several weeks before it per- manently disappears. Hemorrhage, as previously noted, can usually be controlled without any serious difficulty, but rarely it may be quite profuse and seriously compromise the operation, a case in this relation being recorded by Ludewig in which the bulb of the jugular vein was injured through a cleft in the inferior wall of the tympanic cavity. The incus hook, if used too forcibly, or if the Fallopian canal be defi- cient in this region, may produce a temporary facial paral- ysis from injury to the nerve, and while this accident is rare, yet it is always advisable to have an assistant watch the patient's face for twitching of the muscles during any oper- ative manipulations in this portion of the tympanic cavity. Finally accidents may take place in regard to the incus itself, as it may become impacted in the posterior part of the tym- panum and will be extracted with more or less difficulty by means of the various procedures which have been previously described; or, what is much more serious, careless manipu- lation may dislocate it backwards into the antrum, when a mastoid operation will be necessary for its extraction. Before considering the question of the advisability of removing the stapes in chronic suppuration of the tympanic cavity, the method of cutting the tendon of the stapedius muscle will demand some consideration, and as before men- tioned, this procedure is often performed as an initial step in removing the ossicular chain, as it brings the incudo- stapedial articulation more into the line of vision. The pro- cedure requires but little description, as it is readily per- The Treatment of the Ossicles. 127 formed by inserting a straight knife above and behind the head of the stapes and between it and the tympanic ring; it is then directed inwards until its point lightly touches the inner tympanic wall, when it is slightly withdrawn and the tendon is severed in a direction downward. While but few otologists claim that the removal of the stapes is either necessary or free from danger in suppura- tive conditions of the tympanum, the greater number exer- cise a more conservative feeling in this respect, and advise not only that this ossicle should be removed, but that in the presence of pus in its locality, it should be avoided in every way and should not even be mobilized for fear of the infec- tion passing through the oval window and producing serious, if not fatal, change to the labyrinth and intracranial struc- tures. Undoubtedly, the latter position is not only safe and eminently surgical, but is also expressive of the best interests of the patient, the author not being of the opinion of those who remove the stapes, even if it is found somewhat carious, although the position of Grunert may be well taken that the removal of this ossicle is not necessarily followed by injury to the hearing, nor an intracranial lesion. The method of removing the stapes presents but little difficulty when the malleus and incus have been removed and the stapedius ten- don severed, as with a straight knife it is freed from its attachment to the notch of the oval window, and with a sharp or blunt hook placed between its crura it is removed by carefully drawing it out. That the removal of the stapes in the presence of a suppurative process in this region is extremely hazardous, is well shown by a case reported by Politzer, in which this ossicle was accidentally removed during the performance of a radical operation and was fol- lowed by the death of the patient. Sections of the parts showed a granulation tissue mass filling the niche of the oval window and passing through the labyrinth window into 128 Suppuration of the Middle Ear. the vestibule, where it filled the whole of the cisterna peri- lymphatica. The utriculus showed inflammatory thicken- ing, horizontal semicircular canal was filled with a con- nective tissue network between the membraneous and osseous canals, and was filled with round cells and dilated blood- vessels, while the cochlea was also seriously compromised by the inflammatory changes. Another method of removing the ossicles and curetting the morbid tissue from the attic is that of Vasher. This is performed under general anaesthesia by detaching the upper half of the membraneous canal by an anterior and posterior incision through the soft tissues from the tympanic cavity to the auricle, the incisions being made from within out- wards. The superior half of the canal is then separated from the osseous tissue with an elevator or blunt spatula and pulled outwards, the periosteum and osseous tissue above is then scraped away, so that a large part of the osseous entrance of the canal is exposed to view. In order to obtain a large cavity it is also suggested that the entire upper wall of the canal be removed and also a part of the outer wall, so that the ossicles may readily be removed and the attic thor- oughly curetted. After removing the diseased tissue in this way the incised portions of the canal are again placed in position and firmly retained in place by a narrow strip of gauze placed against the upper external wall of the canal to avoid any tendency towards atresia which may occur. In those cases where the tissue flap has been in great part destroyed by its removal it is necessary to entirely excise it and allow the parts to heal by granulation. Practically this operation aims to accomplish the same results as a Stacke without, however, detaching the auricle, but it must of necessity fall far short of accomplishing any such results, as in those cases where the symptoms point to the removal of the ossicles through the canal by the methods previously The Treatment of the Ossicles. 129 mentioned, such an operation as this presents no advantages at all and many disadvantages, while in the class of cases in which the carious process is more extensive, a Stacke or even more radical operation is absolutely indicated, as by the Vacher method all the diseased tissue cannot be removed, and at the same time the danger of serious stenosis of the auditory canal is greatly enhanced. In all the operations here described for removing the malleus and incus, the chorda tympani nerve as it passes in intimate relation with these ossicles is practically always destroyed, but this is of little moment, as the most serious result from this is a partial loss of taste and in practically every case the alteration lasts but a few weeks at the most. While this is a more or less essential incident to this opera- tion, yet more serious accidents are sometimes apparently unavoidable, the majority of which have already been pointed out, but it is further desired to mention here that the facial nerve may be damaged, so that facial palsy or paralysis will ensue; however, such an untoward event during an ossicu- lectomy is not common, and as usually happens, the result- ant paralysis is amenable to treatment. Marked impair- ment of hearing is a most unfortunate accident that may result from damage to the stapes by its impaction in the oval window, or still more serious consequences may ensue from labyrinthine injury, the result of accidental removal of this ossicle either as the result of traumatism during the course of the operation, or by the extension of the purulent inflammation through the exposed oval window, to the inter- nal ear. As regards the hearing, however, being altered in any respect as the result of the ossiculectomy, but little evi- dence can be offered on this point, as the primary and sole object of the operation is to prevent the further extension of the purulent inflammation, or to cure the otorrhcea, and the question of hearing, while of great importance, yet must 130 Suppuration of the Middle Ear. be of secondary consideration. When the suppurative otitis is associated with impairment of hearing, the result of the excessive secretion and morbid tissue filling the tympanic cavity, so that the ossicles are rigid and sound waves are pre- vented from being transmitted to the inner ear, then one can expect a marked improvement in the auditory acuity as the result of the now valueless malleus and incus being removed, by allowing the sound waves to reach the stapes and inner tympanic wall without obstruction. One can never judge, however, by the impairment of hearing the extent of the morbid process in the tympanic cavity, but as a rule when the patient seriously places the results of the operation as regards his hearing foremost, it is well to avoid ossiculec- tomy if such be possible in those cases where the hearing is near the normal; for while in the larger number it remains uninfluenced or even slightly improved, yet in the smaller number it is apt to become very much impaired. The final results in ossiculectomy, as regards the cure or amelioration of the chronic suppuration, are usually most satisfactory when the accessory cavities or walls of the tym- panum are not too extensively involved, Kretschmann in thirteen cases cured eight ; Stucky in twenty-nine had twenty- four cures; Alderton in twenty-two consecutive cases had fifteen cures and four cases which improved, while Grunert had thirteen cures in twenty-eight cases; Dench fifteen in twenty-nine; Ludewig forty-two cures in seventy-five opera- tions, and the author had twenty-three cures in sixty-eight operations. By removing the ossicles, not only is the dis- eased tissue removed and the drainage improved, which in itself tends towards the restoration of the parts, but the suppurative process is in the majority of cases prevented from extending to more dangerous areas and even when the tympanic walls are involved to some degree, recovery may ensue as these parts are thus placed in a position where they The Treatment of the Ossicles. 131 can be directly treated. In some cases the suppuration ceases within a few days or weeks after the operation, and but little after treatment is required, while in others it may require a number of months before this desirable result is obtained, or although the suppuration may be lessened by the ossiculectomy, yet its prolonged continuance will suggest the presence of carious bone still remaining and radical oper- ation will be required. In all such cases, however, where the suppuration continues for a number of months after removal of the ossicles, it is well, as pointed out by Grunert and Zeroni, to delay the radical operation for a considerable time, as the suppuration may finally cease as the result of continued after treatment. CHAPTER V. THE TREATMENT OF CARIES OF THE TYMPANIC WALLS, THE EPITYM- PANUM AND HYPOTYMPANUM. 133 THE TREATMENT OF CARIES OF THE TYMPANIC WALLS, THE EPITYMPANUM AND HYPOTYMPANUM. Inasmuch as carious processes involving the walls of the tympanic cavity do not, as a rule, occur alone, but are always intimately associated with morbid changes of the mucous membrane and frequently, but to a less degree, with caries or necrosis of the malleus and incus, it is evident that the pathological products, acting both as a cause of necrosis and caries and resulting in great part from these changes, have to some extent been described in the preceding chapters. It is desired here, however, to more intimately describe the sur- gical treatment of the carious changes in the tympanic walls and adjacent regions accessible through the external canal, either in those cases where it is not necessary to remove the ossicles on account of the bone disease being limited in area and easily accessible, or in the much larger class where the ossicles are involved and the molecular changes in the attic or lower tympanic walls are in intimate association with the presence of polypi, granulation tissue or cholesteatomatous masses, the latter especially being always indicative of a sup- purative process of such duration that the coincident pres- 135 136 Suppuration of the Middle Ear. ence of osseous lesions may generally be presupposed. The recognition of a carious area involving the walls of the tym- panic cavity is usually absolute should the mucosa in defi- nite regions become markedly altered in color, or present a pale yellow-gray appearance, and the probe, when inserted through these patches, transmits a decided feeling of rough- ness to the examiner's hand. This appearance, however, is not often so characteristic and in the great majority of patients with chronic otorrhcea one cannot be certain as to the pathological findings in the osseous tissue hidden beneath the mucoperiosteum until the contents of the tympanum have been entirely removed. In still another group of cases, although the ossicles are involved, there will be no apparent subjective or objective symptoms indicating extensive dis- ease of the osseous walls until later radical operation reveals it after the suppuration has continued in spite of ossiculec- tomy and treatment directed to the mucosa. While the diagnosis of this condition is so often difficult and at times even impossible, it is usually located at such a position that it is inaccessible by way of the canal, and therefore treatment by this route will prove futile in removing the cause of the continued suppuration, even though the ossi- cles be removed and the granulations and epithelial masses be thoroughly curetted away. In many cases the carious area, although accessible through the canal, will be entirely covered with a mass of exuberant granulation tissue, so that its detection depends entirely upon the careful search with the blunt flexible silver probe, especial care being exercised in all cases when probing the internal wall to avoid pene- trating into the labyrinth through a soft and disintegrated spot of bone in this situation, and when the disease is seem- ingly confined to the walls and the ossicles are in situ, one must always be cautious in handling the probe in the then restricted space that the ossicular chain be not damaged in EXPLANATORY NOTE TO PLATE XVII. A schematic side view of the tympanum showing extensive necrosis of the upper lateral canal wall, necrosis of the malleus, absence of the incus and stapes, and a large perforation in the upper portion of the drum membrane, through which a polyp protrudes. i, Necrosis of the canal wall; 2, necrosis of the malleus; 3, polyp. 138 PLATE XVII Treatment of Caries of Tympanic Walls. 139 any way. One should also avoid penetrating the soft tissues with the probe as far as possible and great care must be exercised when the osseous region under examination is diploetic, as this form of bony structure seems especially susceptible to infective agencies and fresh areas may be unin- tentionally opened up and infected, which will rapidly pro- duce extensive and even serious osseous lesions. In many instances no positive results as regards the pres- ence of osseous lesions of the walls will be ascertainable by the most careful probing, and then in order to obtain fairly definite indications for operative procedures, it will become necessary to base the diagnosis by the complex of the various symptoms present, so that, in many instances at least, fair presumptive evidence of the presence or absence of caries may be obtained in this way. Of these, the more or less irregular recurrence of uncomfortable sensations, or even pain, referred to the deeper portions of the ear is quite sug- gestive of a carious lesion, especially if the pain of reten- tion, as previously mentioned, can be eliminated, and in addi- tion it assumes a more distinct character as night approaches. The secretion from the middle ear may contain gritty par- ticles of bone when the rcognition of the condition is of course absolute, but when such are absent, it affords little evidence as a presumptive sign unless it is thin, offensive and resembles the pus seen from bone sinuses in other por- tions of the body. Marked changes of the mucous mem- brane may be added to this group, such as excessive infiltra- tion, especially of limited areas, or when these changes have produced polypi or granulation tissue, the latter rapidly re- curring after its removal. Excessive infiltration or inflam- mation of the lining of the external auditory canal espe- cially if associated with larger or smaller fistulous openings, is also of value in the cases where other evidences of caries are very slight or altogether absent, but it must also be 140 Suppuration of the Middle Ear. remembered that the absence of these various symptoms does not necessarily imply that caries is not present. The relation between caries of the walls and alterations of the ossicles is very intimate, and although the latter are usually involved at first, yet in cases of long standing, the removal of these is not sufficient alone to cure the suppura- tion, but it is also necessary to curette the tympanic space in part or its entirety, depending of course upon the severity and extent of the lesions present. One should therefore never feel satisfied that the cause of the suppuration has been removed when the malleus and incus have been dis- posed of, as often this is but a single step in the complete operation, and one cannot consider it completed until all the diseased osseous tissue has been removed from the tympanic cavity. On the other hand, the indications are such that the question of removing the ossicles cannot be considered, even if one or both should present slight evidence of a carious process until more conservative treatment has been given a fair trial, and the recognized carious areas of the tym- panic walls be curetted, if they be in such a position that this can safely be performed. Usually, if the lesion be at all extensive, the treatment of carious tympanic walls with- out removal of the ossicles will result in failure, but in a smaller moiety of cases, with the lesion limited to the prom- ontory, or possibly a portion of the tympanic ring alone affected, one may obtain a favorable result, especially if an energetic after treatment be employed. The amount of purulent discharge, aside from its quality, should also be taken into consideration in determining the presence or absence of osseous lesions, as when the otorrhoea has been long continued, often extending over a period of many years, and the discharge is poured out from the tym- panic cavity in large amounts, it is very suggestive of caries of the tympanic walls, as the ossicles in such cases are often Treatment of Caries of Tympanic Walls. 141 reduced to mere irregular fragments and play but a modest part in the suppuration at this stage. It must also be remem- bered that a profuse discharge means that a considerable amount of tissue necrosis is taking place, and while this does not always presume that such tissue destruction is in great part osseous, yet it is impossible for such to occur during a more or less protracted course without a certain degree of tympanic involvement. Further than this, the purulent discharge originally from the mucosa produces further changes here which seriously interfere with the nu- trient blood supply to the osseous tissue which of necessity, if it be sufficient, produces localized carious areas and when in addition to this, the irritating effect of the pus on partially exposed bone is considered, one may be fairly safe in advis- ing operative procedures of this nature in intractable otor- rhoea, with the expectation of finding the tympanic walls more or less necrosed. While the treatment of the conditions described embraces the care of the entire tympanic cavity, yet in many ways it is more practicable to divide this cavity into two portions, the attic, or epitympanic space, and the atrium, or lower tym- panic space, and especially is this advisable on account of the preponderance of severe morbid changes in the former situation. With the brunt of the suppurative inflammation borne by the attic, one finds that most frequently its external wall is involved, as its vascular supply is limited, and it is in close association with the inflammation of the attical con- tents, its structure being formed by the auditory plate. The internal wall, however, is but seldom affected, and when it does become involved the patient is apt to complain of some degree of vertigo from the inflammation involving the stapes and vestibule. When the pars epitympanica becomes carious the opening in Shrapnell's membrane is very apt to be irregular in outline from the erosion of this margin of 142 Suppuration of the Middle Ear. the bony wall, or when the vault of the tympanum is involved with or without the pars epitympanica being markedly affected, the perforation, as mentioned in another chapter, is located in the postero-superior quadrant of the mem- brana tympani, and usually just below the location of the incudo-stapedial joint, while the lower portion of the mem- brane is very apt to be adherent to the inner osseous wall, the superior portion remaining free. These characteristics of tympanic caries result from the manner in which the pus travels from this region to escape in a lower position, and this is accomplished by the fluid flowing down the long process of the incus; the purulent matter being restricted to this route in cases where the ossicles have not been de- stroyed, as it is the only portion of the ossicular chain which passes directly from the attic down into the atrium. In some cases it is possible to determine the presence of caries by a sinus leading directly into the vault of the tympanum and granulation tissue protruding from the mouth of the sinus is almost certain evidence that an osseous lesion is present. A mass of granulation tissue arising from the pos- terior and superior portion of the tympanum is also strongly suggestive of the same origin, and probably in the imme- diate neighborhood of the antrum, the amount of purulent discharge being somewhat of value in determining the extent of the lesion, as, if it is profuse, one would be inclined to consider the lesion of considerable extent, while, were it scanty in amount, the area of bone necrosis would probably be small and possibly, as in some of these cases, aside from the ossicular involvement, limited to but the small edge of bone forming the entrance to the antrum. The removal of the outer attical wall is indicated in those cases where the perforation is in Shrapnell's membrane and the residue of the purulent inflammation is apparently lim- ited to the region of the attic, and in which there is but little Treatment of Caries of Tympanic Walls. 143 disturbance of audition, so that the ossicles are not exten- sively involved and should not be removed, the excision of the carious external wall with the removal of the morbid tissue from the vault usually being all that is indicated. The method of removing this bony wall may be by simple curettage with a sharp spoon or by a punch. The sharp spoon is employed in removing this portion of the tympanic margin by cutting away the carious bone by firm pressure from behind forward, care being taken that the malleus and incus are not injured, and by curetting the bone away, which is usually quite soft at its inferior border, the external attical space may be sufficiently opened to remove the ob- struction to free drainage, or in case the caries is to a great extent limited to the margo tympanicus, its removal in this manner will be sufficient. As an independent operative pro- cedure, the removal of the pars epitympanica alone is but rarely indicated, as it is exceptional to find caries involving this part without involvement of the incus. Should the tympanic caries be extensive, the removal of the pars by way of the canal will not be sufficient, and then a procedure such as Stacke's operation will be indicated. Another method of opening the attic is by the removal of its external wall with a forceps-chisel, of which several varieties may be obtained. The perforation in the membrana tympani should be en- larged if necessary, so that the instrument may be inserted into the tympanum and its anterior hook-shaped portion grasp the inner portion of the external attic wall. In this way the bony plate which is to be removed lies between the hook-like plate of the instrument on its inner side and the chisel portion externally. This procedure is repeated several times, when the instrument is withdrawn in order to remove the small pieces of bone from it and to control bleed- ing and see the amount of tissue removed, and if some necrosis is still present, the chisel is again placed in position 144 Suppuration of the Middle Ear. and particles of bone removed in the same manner until all the involved tissue has been cut away. With some of the newer models of this instrument, it is surprising how rap- idly and how safely the external attic wall can be removed and with a minimum of danger; the greatest care being required, however, that the ossicles do not become displaced from pushing the end of the instrument too far inward. Of course one cannot expect to remove the wall here as thoroughly through the canal as by a post-auricular oper- ation, but if the area of caries be small and no other indica- tions exist for the larger operation, it is often possible to materially aid the chronic suppuration by removing the carious bony tissue in this way. This method of opening the attic, while of value in practically all cases where the carious process is not too extensive, is of special service in those cases where the suppurative inflammation has in great part become limited to the external attic space, that is, that portion lying between the malleus and incus internally and the wall of the tympanum externally. In such cases of the so-called external atticitis the purulent discharge is usually quite scanty, there is but little or no odor except when reten- tion takes place for a lengthy period and the perforation is in Shrapnell's membrane, often in intimate relation with the carious edge of the attic wall, so that here one often finds a small patch of granulation tissue concealing the dead bone. As shown by Batey, this form of atticitis is the result of the chronic tympanic suppuration finally becoming local- ized in the external attic, and as the head of the malleus, with the body and short process of the incus, project into the attic, they form, in conjunction with its external wall, a more or less confined space into which the pus can drain from the parts superior and posterior to it. By removing the external retaining wall in the way heretofore described, that is, either by curette or forceps-chisel, an open space is Treatment of Caries of Tympanic Walls. 145 made of this heretofore enclosed area, and if the granula- tion tissue usually present be snared or curetted away, one is often able in such cases to obtain a comparatively large space with no restriction of drainage, so that the suppura- tive process either heals within a very short time or after additional local treatment which can now be readily carried out so that the ossicles can be allowed to remain in situ and a Stacke or other more radical operation will be avoided. When the epitympanic regions are curetted through the canal, certain disadvantages are necessarily encountered which are not present when the field of operation is laid bare, as in the post-auricular operations. Unfortunately, even when the pars epitympanica has been thoroughly re- moved, the attic must be in great part curetted by touch alone, as it is impossible to see all that is being done. For this reason one must always proceed most cautiously in this region, and further, it is not always possible to ascer- tain that all diseased tissue here has been removed, although the careful use of the probe used to locate any carious areas will be of great value in aiding one to eliminate all the diseased tissue in a large number of cases. But it is much more satisfactory and probably will conserve the interest of the patient more efficiently if operation through the canal be refused in cases where the attic and possibly the antrum show extensive lesions and one is in doubt as to the ability to remove all the morbid tissue. Another method of removing the pars epitympanica to obtain access to the attic region is by the use of the burr driven either by the electric motor or the ordinary dental engine. This has been used to some extent abroad, but in this country the cylindrical burr used for this purpose has not proven as satisfactory as the curette or forceps-chisel, although by its use the attic wall can be quickly and easily removed, some cases having been recorded in which the whole of the antrum ii 146 Suppuration of the Middle Ear. has been thus exposed. In using this instrument it is abso- lutely essential that the external auditory canal be very broad and not too deep, so that a burr with a short shank may be employed. If the attic alone is to be opened, Strum advises the use of local anaesthesia, but where it is to be employed in removing carious bone from other areas, such as the inner tympanic wall, general anaesthesia then becomes necessary, and this author also finds that in opening the attic wall the instrument readily penetrates the thin dermal lining of the canal, so that section of this part is unnecessary, while the only untoward effects seen after the employment of this instrument here has been some tinnitus, which always subsided after a short time. The portions of the tympanic cavity and its neighboring osseous relations most frequently involved in the carious process, and which may be reached, in part at least, through the canal, are especially the tegmen and outer wall and the portion of the external wall in close connection with the tympanic cavity, which is formed by the auditory plate of the temporal bone. Where the tissue is in this way pneu- matic in structure, it is much more frequently involved than the compact or diploetic osseous tissue, as the latter presents a much greater degree of resistance to the purulent infec- tion than does the former, the postero-superior wall of the external canal being usually involved, then the wall of the promontory, the tegmen tympani and the anterior wall of the meatus usually following in the order named. This is, however, not at all constant, as the parts involved at first in the carious process, irrespective of their location, are those that are the least vascular and in which the nutrient vessels are readily interfered with by changes in the tympanic mu- cous membrane or by any increase of pressure in the tym- panic cavity. Rarely it occurs that a single area is carious, such as a small spot on the promontory, but as a rule several Treatment of Caries of Tympanic Walls. 147 carious areas are found and if the mucosa be greatly in- volved, all the anatomical points mentioned will be found to be more or less affected. While the basal cause of the caries of the tympanic walls is the serious interference with the blood supply as previously pointed out, local causes are essen- tial to bring about this condition, Politzer classifying as the most important of these local agents the retention of pus in the middle ear from stricture of the canal; the presence of polypi, granulation tissue and cholesteatoma and stagnation and decomposition of the purulent discharge, or of an accu- mulation of epidermic masses which produce ulceration of the mucous membrane of the tympanic cavity and thus ex- posing and causing caries of its underlying osseous walls. This is in great part favored by the mucosa acting both as a mucous-membrane lining for the tympanum and also as its periosteum carrying the nutrient blood supply. The result of this is well shown by the more extensive osseous destruc- tion taking place in children than in adults, on account of the structure of the periosteal layer of the mucous membrane in the former being greatly more vascular and containing rela- tively more numerous and larger vessels than pass into the osseous tissue. General morbid states may also play a prom- inent part in determining the rapidity and extent of the osseous involvement, as in syphilis and tuberculosis, the pro- fuse formation of pus with its retention at times allows the pathological organisms to invade the mucosa to a greater degree and with the inflammation thus produced of its deeper layers the round cell infiltration obliterates the vascular chan- nels, and shutting off the blood supply, causes the periosteal layer to separate from the underlying bone with its subse- quent necrosis. The indications for removing the carious areas must of necessity greatly vary in almost every case, and especially so in that group where, on account of the suppuration, radi- 148 Suppuration of the Middle Ear. cal operation must also be taken into serious consideration. Such cases in which operation through the canal for this purpose is indicated instead of post-auricular opening of the antrum and attic, are those in which the membrana tympani has been in great part destroyed and the mucous membrane of the cavum tympani has undergone a considerable amount of hyperplasia with but slight osseous changes, although small carious areas may be present on the inner tympanic wall. Another group belonging to this class shows usually a small irregularly placed perforation of the membrana, and there is a constant tendency for the suppuration to cease, then to recur again on the slightest causes, such as an attack of coryza. In these cases the patient is not annoyed in any way by his aural condition when the discharge is absent, as it not infrequently happens at such times that the per- foration entirely closes, while again the discharge comes on and relief is sought only for this annoying tendency to the recurrence of the discharge. Another class has been de- scribed where the problem of deciding what operation to perform is somewhat difficult, and that is in those patients with good hearing, but a constant suppuration of both ears ; no immediate indications for operative procedure being pres- ent except the continued purulent discharge. In such cases antiseptic treatment should be continued for many months, and then if no impression be made upon the affection, it seems the best plan to remove the carious bone from the walls without disturbing, as far as possible, the ossicles, one ear being treated in this manner and the other allowed to remain free from operative interference until the process has been conquered if such be possible in this way, and if no impair- ment of hearing results, then the other ear may be curetted in the same manner. The changes in the osseous walls as the result of the sup- purative process vary in the different portions of the tym- Treatment of Caries of Tympanic Walls. 149 panum, depending upon the extent of the diseased process and the resistance of the bony tissue. In one part the bone may be degenerated and undergoing absorption, in another part the carious and necrotic process is so marked that the bone at that point is in process of exfoliation. Surrounding the carious areas, the bone is usually much harder than nor- mal, as the result of the growth of cells into it from the muco- periosteum, so that the increased vascular dilatation in such areas with an augmentation of the bone cells, produces this condensation with the development of a hyperplastic condi- tion. Where the process has been latent and of long evolu- tion, the spaces in the bone at first filled with granulation tissue, later become ossified and the walls so affected become increased in thickness, thus isolating to a greater extent than usual the suppurating middle ear from the surrounding parts, as it were, and as this newly formed osseous tissue also loses its nutrition, necrosis will be found in the areas of the thinner parts. Over these carious or necrotic areas, gray colored unhealthy masses of granulations spring up, while the mucosa is ulcerated, and if the soft tissues should be removed without curetting the carious bone they rapidly recur again and in neglected cases after the tympanic cavity has been cleansed of these granulation masses often mixed with epithelial debris and inspissated decomposed pus, one often finds the walls of the cavity eroded in one place, while in another the thickened wall will show projections of most irregular shape and form of osseous outgrowth, which will require a fairly strong sharp spoon for their removal. Ex- foliated spicules of bone from the overgrowth of the walls in part and not from the partially destroyed malleus and incus are also occasionally found and must be removed with forceps and in some instances a well-marked ulceration may be seen in the wall of the promontory, penetrating into the bony lamella of the labyrinth, although the osseous tissue 150 Suppuration of the Middle Ear. may not be seriously damaged, as only its superficial layer is affected; the apparent depth of the ulceration resulting from the increase in thickness of the greatly hypertrophied mucosa. After the carious tissue has been accurately determined by the probe, either before or after the exuberant granula- tion tissue has been curetted away, as must be determined in the individual case, the softened bone should be removed with the curette, the amount of force used being determined by the location of the involved tissue, but at no time should it be excessive, as serious damage may ensue. The curette must vary in shape and size, depending upon the location of the carious tissue; for the lower tympanic space it may be straight, while for the attic it is necessary to use sharp spoons bent at various angles, a right-angle spoon, however, always being necessary, and when curetting these parts, it should be remembered that although the ossicles may be removed and the morbid mucous membrane extirpated, the success or failure of the operation will depend on the thoroughness with which necrotic and carious areas of the tympanic walls have been removed. As has been pointed out by Politzer, in many cases of tympanic wall caries the curetting is suc- cessful only when the carious process has not extended to too great a depth, for if it be deeply seated the curetting will not prove of much service, and as it is not always possible to tell by the probe the depth in the bone to which the process has extended, one should never curette to a greater depth than one or two millimeters, as a penetration deeper than this may enter into the cranial cavity or labyrinth. Should the caries be limited in extent and but slightly superficial, gentle curetting will usually be sufficient to bring about the restoration to the normal of the parts, particularly if the morbid tissue filling the tympanic cavity in part or whole be removed so that the freshly curetted walls are kept free from Treatment of Caries of Tympanic Walls. 151 the irritation and reinfection of the purulent secretion for a short time. Either in this form of superficial caries or when the bone is more seriously involved, the sharp curette should always be used in preference to the dull instrument, which is of value in removing granulation tissue in certain situa- tions and when the caries is well defined it should, as far as practicable, be entirely removed, the ring curette or sharp spoon being very efficient for this purpose. While it is not usual to find caries of any consider- able moment in the hypotympanic space, yet such a condi- tion does occur and great circumspection must be used in curetting the diseased area if such be found here. When it does occur in this locality it is apt to involve the small pneumatic spaces which in some cases connect the infe- rior tympanic floor with the carotid canal, and one must cautiously explore these spaces, if they be present, in order to remove all the dead bone if such can be done without danger to the important structures here, the air cells of this region sometimes extending externally between the lamella of the anterior and inferior walls of the external canal. One should be careful when using the curette in the tympanic cavity to differentiate between dead and healthy bone, as it does not necessarily follow that because an area of bone has for any reason been exposed that it is carious, and if such a bare osseous surface be healthy in appearance and not rough in any way, it is very probable that it is healthy and should not be touched. If there be any doubt as to the via- bility of the exposed area, however, and it seems impossible to determine this question, if other dead bone be present it is usually advisable to curette all the suspected areas, as the entire success of the operation may be seriously compromised if some of these changes, which seem doubtful or trifling in extent, are not removed, but are left to remain to act as foci for further suppuration. 152 Suppuration of the Middle Ear. In some cases of chronic suppuration, although more frequent in acute cases following the exanthemata, one may find well-marked areas of superficial necrosis with seques- trum formation. This occurs most frequently at the pos- tero-superior portion of the external canal wall and may be rarely discharged in the pus, or more frequently be par- tially detached as a curved, semilunar, irregular scroll of bone, with its internal edge, if it be not too much eroded, showing the border of this part of the sulcus tympanicus. When found in situ it is usually entirely covered over with a mass of granulation tissue and is not detected until search with the probe for carious bone reveals this detached osseous sequestrum, which may sometimes be removed with forceps, or again is still so firmly attached that it is impossible to remove it without further operative procedures. One may also find a thin sequestrum detached from the region of the promontory as a result of the superficial caries and necrosis of this portion of the tympanic walls, and like that described, it may be entirely covered with the thickened, granulating mucous membrane, which has to be curetted away before the irregular plate of necrosed bone can be removed. This sequestrum may, as in some reported cases, show upon its outer surface a portion of Jacobson's sulcus for the trans- mission of the tympanic branch of the glosso-pharyngeal nerve, and thus if this detached bone be found lying free in the tympanic cavity, the presence of these marks will afiford a valuable clue as to its source and the location of the necrotic area. The removal of a small sequestrum of bone from the tympanic cavity depends upon its size and shape in rela- tion to the capacity of the external auditory canal. If small and lying free in the tympanum, it can readily be extracted with any small forceps firm enough to grasp it. In other instances, however, it may be deeply seated, or in an inac- Treatment of Caries of Tympanic Walls. 153 cessible portion or may again be deeply embedded beneath a mass of granulation tissue and if not too hard, when its size will not allow its removal through the canal, an attempt may be cautiously made to crush it, when, if this is successful, it can readily be removed with forceps or by syringing. In some cases, however, this will be impossible and detachment of the auricle with or without removal of portions of the osseous wall of the external canal will be necessary before it can be extracted. After the walls of the tympanic cavity have been curetted and all necrosed and carious tissue re- moved, one should then carefully examine the tympanic ring, as it is frequently involved to a greater or lesser degree. This is especially so in regard to its superior and postero- superior margins, as in this part it is in very intimate rela- tion with the ossicles and forming as it does part of the floor of the epitympanic space, it is especially liable to carious processes at these points. Should the ring be involved to any great extent in conjunction with morbid changes in the tympanic cavity, it will be almost useless to attempt to oblit- erate the diseased parts by way of the external canal, as in such cases it is usually found that the caries also involves the antrum and possibly the mastoid cells, and is of course inac- cessible through the canal. In cases, however, where the bone shows some softening or roughness over a limited area it should be treated the same as the walls of the tympanum, and with sharp spoon or curette the diseased tissue should be removed down to firm healthy bone, or if desired the part of the ring involved may be excised with cutting forceps and then smoothed down with the curette. Finally in all cutting operations for the removal of carious or necrosed bone, either from the walls of the tym- panum or its immediate vicinity, one must always bear in mind that certain dangerous elements are always present. Of the least of these, nausea and vertigo often occur, but are 154 Suppuration of the Middle Ear. usually transient and result from some temporary trauma- tism to the stapes, while as more serious may be noted facial paralysis, which readily disappears within a short time if the nerve has not been too seriously damaged, and one may also perforate into the cranial cavity through the tegmen tympani, when the curetting should be immediately stopped and a post- auricular operation performed to remove all the necrosed bone, and thus protect the cranial contents from infection. CHAPTER VI. THE AFTER TREATMENT OF OPERA- TIONS THROUGH THE EXTERNAL AUDITORY CANAL. '55 THE AFTER TREATMENT OF OPERATIONS THROUGH THE EXTERNAL AUDITORY CANAL. When an ossiculectomy has been performed, granulations and cholesteatomatous tissue removed, or the tympanic wall curetted to remove carious bone, much has been done towards the desired aim of relieving the patient of the suppurative otitis media, but if minute and careful attention be not given to the after treatment of these cases little will ultimately be accomplished in the vast majority, as this care of the tympanic cavity, both in order to obtain prompt resolution of the tissues which still remain, and to prevent by careful attention to details the further breaking down of other tis- sues, is always essential in every case where operation has been performed through the external canal. In other words, the various operative procedures performed in this way have been aptly described as being only steps towards the perma- nent relief of the suppuration, the local care of the affected tissue after the operation, being fully as important, and during this after treatment it should always be borne in mind that in obstinate cases the curetting of newly formed granu- lation tissue or the removal of additional areas of carious 157 158 Suppuration of the Middle Ear. bone, will from time to time frequently be necessary. The main element of success in the treatment of such cases is the scrupulous attention to minor details, with patient watch- fulness as regards the care of the tympanic cavity. As, for sake of clearness the various operations upon the tympanic walls and its contents have been described in the previous chapters as independent operations, but which are one or all performed at the same time in many cases, so it is desired here to consider the treatment following opera- tion in the same manner as more clearly descriptive of the various conditions. After a perforation in the membrana tympani has been enlarged, or a second perforation made in order to evacuate retained pus, the parts should be cleansed with an antiseptic solution, such as 1 : 5000 bichloride solu- tion, and the inspissated material usually present washed out of the tympanic cavity with a delicate cannula, or pref- erably, Blake's intratympanic syringe, until the fluid comes away perfectly clear. The parts are then mopped with a sterile cotton tuft dipped in peroxide of hydrogen solution, and this is alternately repeated until free drainage is ob- tained and the portions of the tympanic cavity accessible through the perforation or perforations, with the external auditory canal, are rendered as clean as possible. Upon the amount of purulent secretion discharged from the tympanum does the further treatment depend. Should the discharge be profuse, the external meatus is lightly closed with cotton and the ear should be syringed frequently with a warm, nor- mal salt solution; in other cases, after cleansing the canal, sterile or iodoform gauze strips are lightly packed into it, reaching well to the perforation, and the parts are then drained into a cotton pledget placed at the external orifice, and which may be changed by the patient should it become moist, but under no circumstances should he be allowed to disturb the gauze drain. In still another group, where the Operations through External Auditory Canal. 159 discharge is scant, the best results have seemingly been ob- tained by gently dusting over the membrana tympani and walls of the canal an antiseptic drying powder, such as boric acid, acetanilide, or those containing iodine, these latter being of the most service in the majority of instances. When the membrana tympani has been removed in its entirety as a preliminary procedure for an ossiculectomy or curettage of the tympanum, the treatment becomes part of the operation of which this procedure is but a part, and in itself requires no special mention except that when it shows a tendency to reform as a cicatricial membrane it should be removed as previously described and the annulus lightly cauterized at several points with chromic acid or nitrate of silver, unless the suppuration of the tympanum has ceased, when the question of its presence or absence depends entirely upon the hearing and its effects upon it. As a cardinal principle in the after treatment of these various operations through the external canal, the nearer one approaches a strictly aseptic plane the more promising will be the final results, and not only should this surgical clean- liness be enforced in regard to the tympanic cavity and ex- ternal auditory canal, but that portion of the auricle in rela- tion thereto should also be carefully kept cleansed in order that the entrance of further infective material be prevented to as great an extent as possible. While such precautions may seem not only unnecessary but also entirely useless in the treatment of a suppurating ear already infected, yet such is not the case by any means, as this adherence to strict anti- septic surgical principles has a two-fold purpose, both by preventing to a great extent the entrance of further and possibly more serious infective material into the already dis- eased parts, and secondly, it aids in diminishing both the quantity and virulency of the organisms already present. While the desired surgical cleanliness as regards the tissues 160 Suppuration of the Middle Ear. at the most can be but relative, yet as concerns the instru- ments and dressings used in the after treatment, it can and should be absolute and nothing should be placed in the ex- ternal canal, including even the speculum, but what has been properly sterilized. This care is especially important as regards the dressings used, as it is impossible to expect a suppurating ear to cease discharging unless the gauze used in draining the canal, for instance, be sterile, and it is also highly important in this connection to remove the dressings, if such be used, before the purulent discharge, if profuse, has saturated them, so that no added danger of retention and increased infection of other tissues can take place in this way. In this respect one can safely premise, as a general rule, that if more attention was paid to the strict aseptic treatment of cases of chronic suppurative otitis, as far as consistent with the nature of the parts after such operative procedures here, the number of cases in which the suppura- tion was eradicated, and radical operation was thereby pre- vented, would be markedly increased, as it seems very prob- able that an unnecessary number of failures or partial suc- cesses result from neglect of this highly important principle. After a single large polypus or a circumscribed polypoid mass of granulation tissue has been snared away, the base and its immediate vicinity should be carefully searched for necrosed bone, and if such be present, it should be removed as previously pointed out, the after treatment for which will be described later, but if such be not found it is essential that the base of the growth be destroyed. Chromic acid is pref- erable for this purpose, although nitrate of silver has been employed to some extent, and with the acid fused on a probe after the tissues have been thoroughly dried the remnants of the growth are entirely destroyed, care being taken that the cauterant is not too lightly applied, so that the parts are only stimulated to further growth, and if the base of the Operations through External Auditory Canal. 161 growth be very small and soft, the destruction is easily accomplished by a superficial application, but if it be firm and large, it is necessary that it be thoroughly burnt away, often several applications at intervals of from one day to a week being necessary to accomplish this purpose. After the base of the growth has been cauterized in this manner, it may be lightly dusted with an antiseptic iodine powder, or what has proven more preferable in some cases, one of the various nonirritating silver salts may be used in diluted solu- tion every day or less frequently, as may be required in the particular case, any tendency to the recurrence of the growth being at once controlled by cauterization. No one treatment is applicable to these cases and even in the same case it is often essential to vary the medication from time to time. One may also use a i : 500 or even stronger solution of for- maline, directly applied to the area of the growth with the cotton tuft. In addition to the powerful antiseptic influence of the formaline, it also markedly constricts the growth. When large masses of granulation tissue have been cu- retted away or the hypertrophied mucous membrane removed by the same means and the parts have been cleansed, the middle ear may be dusted with iodoform or any of the anti- septic powders mentioned and drained by gauze or not, as may seem most satisfactory. In many of these cases, espe- cially if carious bone be present, there is a constant ten- dency towards the redevelopment of exuberant granulation tissue probably for some months after operation. This con- dition is more in evidence if various partly inaccessible niches of diseased tissue in the tympanic walls have been left un- touched. For the purpose of lessening the secretion and producing a more healthy lining for the tympanum, the judi- cious application of 95 per cent, alcohol is very beneficial; it should be applied by lightly mopping the remnants of the altered mucosa once or twice weekly and between these appli- 12 1 62 Suppuration of the Middle Ear. cations the dry dressings should be daily employed if pos- sible, but if not, when the discharge is profuse it will be necessary to syringe the ear in order to remove the exces- sive secretion. Before the application of any of these local measures directly to the mucous membrane, it is very essen- tial that the parts be cleansed of mucus or purulent secre- tion, so that the applications may directly influence the parts to which they are applied, and when the application is made to a limited area where it is desired that its effects be con- fined, these tissues should be always dried after cleans- ing. In the after treatment of the removal of granulation tissue, all new growths which are excessive in development, or which project above the surface, so that folds and crev- ices are found which may retain infective secretion, must be destroyed by the various methods outlined, the objects to be attained here, as also after removal of the carious ossicles, being to produce a smooth, nonsecreting surface to replace the pus-forming pathological tissue which has in part been removed. Carbolic acid in glycerine or water in strength of from i to 10-25 is very useful for this purpose in cases where the secretion is somewhat profuse. When used in the weaker solutions it may be instilled into the ear, and allowed to remain a few moments, when it is removed with the cotton tuft on an applicator, or if the stronger solutions be employed, the parts should be lightly brushed over with the drug, which is allowed to remain for a greater or lesser time as the conditions may seem to demand, and it is then removed or not as may seem must suitable. A favorite mode of healing the curetted surfaces, and one which will produce excellent results in many cases, is a strong solution of boracic acid in water, or even more preferable, is the use of a saturated solution of this agent in absolute alcohol. This is applied to the parts desired in the manner already described, and it exercises a most beneficial Operations through External Auditory Canal. 163 effect in those cases where the secretion is not excessive by markedly drying the tissues, diminishing the discharge and actively restraining the growth of excessive granulation tis- sue, its application being repeated several times daily or less often, dependent upon the effects obtained. Some otologists, after curetting the granulating and hyperplastic mucous membrane, prefer to cauterize the entire raw surface with nitrate of silver or chloride of zinc solutions. This treat- ment at first produces an excessive mucopurulent secretion, but it is claimed that better results are obtained in this manner than by other methods, and in Bonain's cases treated in this manner, which were dressed with iodoform gauze packing changed twice daily, the discharge ceased promptly and but twenty-one days were required as an average to obtain a cure. The reactive inflammation that sometimes takes place after this extensive cauterization is, however, a serious drawback, and although excellent results are ob- tained at times by this method, as a rule one will obtain as good results without the dangers if the various methods as given here be employed. The use of the syringe for removing the debris and puru- lent secretion from the ear after any of these operations should be guided entirely by the width of the external canal and the amount of the purulent discharge. With a broad, wide canal where there is no obstruction to the return flow of the solution employed, syringing is not contraindicated. When the secretion is thick and inspissated and is retained in localities in the tympanic cavity where it is impossible to remove it with the applicator, the use of an antiseptic solu- tion with which the pus is dislodged by syringing is essential after any of these operative procedures, as it is the only means which presents a minimum of danger by which the parts can be rendered at all clean. Filling the ear with per- oxide of hydrogen, either before or after operations through 1 64 Suppuration of the Middle Ear. the canal, is to be deprecated, as it not only serves to dissem- inate the pus and infect new areas, but also when erroneously employed in this manner plays a prominent role in the pro- duction of mastoid infection, and further, when used in the syringe for cleansing the suppurating ear or to aid in the removal of some particle of cheesy pus or broken down epithelial tissue after operation it is always sure to do harm and defeat the objects for which the operation was per- formed. When partially inaccessible portions of the lower tympanic space, and especially the attic, require syringing, one must employ delicate curved cannulas which will reach the parts and be of sufficient caliber to allow a stream of the solution employed to be of use in dislodging the retained secretion, while at the same time it is essential that the syringe and cannulus should be so constructed that they may readily be rendered aseptic. Care should also be taken in keeping the large aural syringe surgically clean when used for washing out the external and lower tympanic space. Syringing may also be indicated if there be much pain after operation, irrespective of the amount of discharge, when the dressings should be removed and any retained secretion or blood clots causing distress to the patient should be removed in this manner. When the discharge is scanty, or if more profuse but readily removed with cotton tufts on the applicator, it will generally be found that the ear should not be syringed ; better results, as regards the more prompt subsidence of the dis- charge and the healing of the parts, being obtained when up to a certain indefinite limit the tissues are maintained as free from the presence of solutions introduced through the canal as possible. This is especially applicable in those cases where the diseased area is limited and drainage is free. With some cases, where the discharge is exceedingly pro- fuse, it may be essential at first to syringe the ear two or Operations through External Auditory Canal. 165 more times daily in order to remove at all the rapidly accu- mulating purulent secretion, but as a rule these cases are the exception, and syringing the ear once daily, when it is indicated, will be sufficient in the majority of cases. The time between the syringing being determined by the amount of pus present, it being the object to cease cleansing the ear in this way as soon as possible, for if long continued it produces a marked tendency towards macerating the tissues both of the canal and middle ear, with the further develop- ment of exuberant granulation tissue. Various solutions may be used for this purpose, depending upon the selection of the operator and the results to be obtained, but they should all be nonirritating and sterile. Warm physiological salt solution is probably the most preferable and harmless for purely cleansing purposes. Solutions of boric acid, bichlo- ride of mercury 1 : 5000-10000, carbolic acid 1 : 100-500, and formaline, the latter very much diluted, are frequently em- ployed with good advantage. The after treatment of cholesteatoma, when removed through the canal, does not differ in any essential respects from the treatment instituted when the ossicles have been removed and the tympanic walls curetted, as the presence of these epithelial masses seem to constitute an essential part of the process when it is extensive. It is necessary, however, to carefully watch such cases where large quantities of these epithelial masses have been removed for a much longer period after the suppuration has ceased than would be the case if they had not been present, and should there be a tendency towards the excessive proliferation of epithelial structures, such areas where this takes place should be cu- retted away as often as necessary, or if the tendency to recurrence is so great that this seems of no service, then a post-auricular radical operation must be performed. When the malleus and incus have been removed and the 1 66 Suppuration of the Middle Ear. tympanum cleansed and as far as possible dried, it is always well for the first day at least to place a gauze drain in the canal and occlude the external meatus with absorbent cotton, the latter being replaced if it should become stained with the discharges. After the first twenty-four hours the treatment must vary in each case, and practically consists in treating the suppurative otitis as before operation in the great ma- jority of cases, excepting that the facilities for local medi- cation have been greatly improved by the removal of the obstruction to the treatment of hitherto inaccessible portions of the tympanic cavity. As in a general way the after treat- ment differs in no respects from the treatment of chronic sup- purative otitis media, it will not be described in any detail here, it being desired to emphasize only those points of the treatment more or less closely associated with the operative treatment of this affection. After the first day, if there are no indications for removing the dressings previous to this, the canal and tympanum should be thoroughly cleansed as described and the tissues mopped with a I to 1000 or I to 2000 formaline solution and a free drain inserted or not as may seem most advisable. Should the discharge rapidly lessen in amount, it is not essential to dress the ear daily, but every other day will often be sufficient. Where the for- maline proves too irritating, causing considerable pain, or later the parts do not improve as they should under its use, it should be discontinued and another remedy employed, such as an alcoholic solution of boric acid or one of the nonirri- tating silver salts, as previously mentioned. Each time the ear is cleansed and medicated, as it were, at least for the first one or two weeks, the plain or iodoform gauze drain should be inserted until the marked lessening of the discharge no longer warrants it, when careful cleansing followed by a dusting powder, will be all that is required. Absolute alcohol may occasionally be indicated to shrink a small recur- Operations through External Auditory Canal. 167 ring patch of granulation tissue or hyperplastic mucosa, and one will find it very efficient for this purpose. In using the gauze drain after ossiculectomy, it should not closely fill the canal, but should be rather loosely packed in it, and should reach from well into the tympanic cavity out into the external meatus, where it drains if the discharge be very profuse into a fairly large pad of absorbent cotton, entirely filling the concha, and retained in place with a small strip of adhesive plaster. When there are any doubts as to the patient interfering with the inner gauze drain, it is well to use two pieces for this purpose, one being placed in the deeper parts of the canal, and after this is in position, another strip of gauze is inserted against the former, so if by acci- dent or otherwise the dressings are disturbed, the tympanic cavity will still remain protected, this method of dressing the ear being of special value in restless children. When it is impracticable to see the case more than once a day and the discharge is profuse, the patient should be instructed to remove the cotton in the meatus only and replace it with a fresh piece should it become saturated, but under no circum- stances should the patient in any way interfere with the deeper dressings at any time, as long as it is necessary to employ this method of dressing. In cleansing the tympanic cavity, and especially the attic, after it has been eviscerated, it is best to employ a bent flexible applicator which when wrapped with cotton will reach all the nooks and crannies and allow of the thorough removal of irritating secretion even well into the aditus, and after this thorough cleansing the necessary medicaments may be employed in solution or as powder as may be desired. In all cases after ossiculec- tomy, the patient must not treat the ear himself in any way, other than to change the external dressing, as already men- tioned, and in a few cases it will be best for the otologist or a competent assistant to dress the ear twice daily for the first 1 68 Suppuration of the Middle Ear. week or so, then the local treatment is carried out as often as may be necessary in the individual case, the time that the discharge takes to reform indicating the necessary duration between the applications to the tympanum. Even in cases where but little after treatment is required and the purulent secretion promptly ceases, the tympanum should be examined at intervals for several months, so that any evidence of an early return of the suppuration may be quickly controlled. In many of these cases after ossiculectomy, the condition as regards the local infection is after a longer or shorter time permanently cured, but in others, although the patient may consider himself well, yet a slight moisture is present in the fundus of the canal, which may show itself from time to time as a slight drying of the secretion into a scab, and as long as this continues the patient should remain under treat- ment. In those cases where there is but a slight serous or semi- purulent discharge, the use of moisture in the middle ear must be carefully avoided, and if necessary to obtain clean- liness the parts should be thoroughly dried and lightly dusted over with an antiseptic powder, boracic acid in impalpable powder being usually preferred when the conditions are as just described and when there is no great tendency to the excessive proliferation of granulation tissue, while when the latter phenomenon is marked, an iodine powder seems to give better results in restraining the growth. Where the tissues are apparently sluggish and resolution seems delayed, while the purulent discharge, while not profuse, is yet more copious than the conditions present would seem to warrant, a solution of one part of carbolic acid in twenty-five parts of glycerine, applied by the applicator once daily or two or three times a week as may seem most suitable in the individual case, will often markedly restore the tonus to the involved mucosa within a short time and produce a rapid amelioration in the amount of the discharge. Operations through External Auditory Canal. 169 While it was stated in the chapter on the preparation of the patient for operation that the upper respiratory tract should be placed in as normal a condition as possible before operation, it is also desired to emphasize in this place, that as part of the after treatment of the tympanic cavity, careful attention should be paid to the nose, and especially to the nasopharynx. Where, for various reasons, this has been impossible previous to the aural operation, any abnormalities which have a bearing upon the latter affection should be cor- rected, and while it is not advisable as a rule to operate in this region for a week or two after an ossiculectomy, yet such should be done as soon as the middle ear irritation has subsided. The main point, however, in this respect, is the careful cleansing of the nares and nasopharynx, so that in- fection through the Eustachian tube is reduced to a minimum and congestion in this region lessened as far as possible. The influence of such care of the nasopharynx especially is well demonstrated in those cases where the ear continues to suppurate despite the fact that the ossicles have been excised, the mucosa curetted and the carious osseous tissue has been removed from the walls and careful after treatment has been faithfully carried out, yet within a short time after a small mass of adenoid tissue has been removed from the vault of the pharynx or from its lateral walls in the vicinity of the Eustachian tube, the purulent secretion from the tympanic cavity ceases, and as long as the upper respiratory tract remains in normal condition, so long does the ear remain perfectly dry. While it is always needful that care be given to the nose and pharynx, those cases in which the purulent discharge from the middle ear is mixed with mucus from the Eustachian tube should receive most careful attention, and in addition to the proper treatment directed to the middle ear, nose and nasopharynx, it is also essential that the tube should be carefully looked after, or any operative procedure will undoubtedly fail to be of full benefit to the patient. 1 70 Suppuration of the Middle Ear. When a small area of carious bone has been removed from the tympanum, either on its inner promontory wall or from the margo tympanicus, without the removal of the ossicles, the treatment after operation will differ in no way from that described when an ossiculectomy has been per- formed, excepting that one must carefully examine the case for a longer or shorter period in order that active measures may be instituted if the carious area does not promptly heal, or if it again recurs. As a rule, the majority of such cases heal promptly and more thoroughly when the affected areas are dusted daily, until healing is completed, with an iodine powder, and as far as the case will admit this dry method of treatment should be strictly adhered to. lodoform, or several of the various antiseptic drying powders of a simi- lar nature, seem to possess peculiar properties of value in these carious cases, and in appropriate instances, if they are intelligently employed, they produce a more or less rapid decrease in the amount of purulent discharge and act as val- uable stimulants to the formation of healthy granulation tissue. If in addition to an ossiculectomy, the osseous walls of the tympanic cavity have been curetted, a somewhat different line of treatment must be adopted, inasmuch as the patient for a time at least must be under observation more closely than when the other operations through the canal have been performed, on account of the more serious nature and extent of this procedure. Immediately after operation and when the bleeding has been controlled, the ear should be thor- oughly syringed with any of the cleansing solutions pre- viously noted and then carefully examined to remove any minute particles of bone which may have been left, or any carious tissue not previously removed, and which may have been overlooked. The walls of the tympanic cavity may then be carefully mopped with a full strength solution of Operations through External Auditory Canal. 171 peroxide of hydrogen on cotton pledgets, in order to get rid of any pus which may still remain and this is also efficient in controlling any slight venous oozing still present. Or the tympanum may be cleansed with a I to 20 solution of carbolic acid added to a I to 500 bichloride of mercury solu- tion, which is very efficient for this purpose where bone lesions are present, but care must be observed that these anti- septics be not used in excess and especially that none of the solution is allowed to escape through the Eustachian tube into the pharynx or is retained in the tympanic cavity, for fear of its absorption and the production of toxic symptoms. After the parts have been cleansed by any of these methods, iodoform or a similar powder should be well dusted over the tissues and an iodoform gauze drain inserted in the canal. This may be left for forty-eight hours without disturbing it if the discharge be not excessive, but as a rule the patient is more comfortable if the dressings be changed in twenty- four hours, as usually the discharge is very profuse for a short time following operation. During the course of the after treatment, the tendency for the development of granu- lation tissue over the exposed bone areas is very marked, and this must be controlled by any of the ways previously described, if necessary the curette being employed from time to time. It may also be essential to curette small areas of bone which may at this time lose their vitality, or a most excellent plan for this purpose, especially when the bone is actually carious, is to use pure lactic acid on a cotton-tipped applicator and rub it thoroughly into the tissues desired. This may be employed as often as may seem necessary, but a week or ten days should intervene between the applica- tions and in not a few of the cases where it is indicated the beneficial results are shown by the development of healthy granulation tissue over the previously denuded bone surface, with later complete cicatrization. 172 Suppuration of the Middle Ear. In those cases where osseous lesions are present and the tympanic cavity is markedly septic, the following treatment has been recommended and will frequently be of considerable aid in these most troublesome cases. It is carried out by packing the canal well into the tympanum with gauze strips moistened with a i to 20 carbolic acid solution and then the end of the gauze in contact with the tympanic cavity is well covered with a mixture of iodoform and carbolic acid solu- tion of the same strength, so that a paste is formed. This dressing is allowed to remain in the ear for a day following the operation and is then changed every one or two days or less frequently as may be necessary, a valuable guide as to when the dressings shall be changed being shown by the end of the gauze becoming saturated with the discharge, when it should be removed and a fresh dressing inserted. At each dressing the ear should be thoroughly cleansed by any of the methods previously advised and any excessive granulation tissue or suspicious bone areas should receive proper attention. For cleansing purposes with this form of dressing the ear may be syringed with a I to 40 carbolic acid solution and if there be any odor present, which is very apt to be noticed for a time, the tissues are dusted with iodo- form powder. As a result of this treatment, in many cases excellent results are obtained, especially when the ossicles have been removed and the walls curetted, in some few cases where the involvement of the tympanic walls has been slight, the discharge will permanently cease within a few days after operation, while in other cases the treatment undoubtedly to a marked degree shortens the course of the purulent process. Whenever gauze drainage is employed after these opera- tions, several factors must be kept in mind. The object of the drain is to draw the purulent secretion from the tympanic cavity and not as an occlusive dressing, which function is taken by the cotton pledget placed in the meatus. It is essen- Operations through External Auditory Canal. 173 tial that when moistened with any antiseptic solution that the excess of the liquid be removed before the gauze is inserted into the canal, for if this is not done, its functions as a drain will be considerably lessened and the object for which it was placed in the canal will be to a great extent defeated. Furthermore, as there is nearly always some slight vascular oozing following curettage, if the gauze does not stop this when it is packed well into the tympanic cavity or carry the excess of secretion away, retention with the formation of a large blood clot takes place and the patient will suffer considerable pain unless the dressings be speedily removed. To guard against retention, it is the most ser- viceable plan to simply lay a small strip of gauze along the floor of the canal and if firmer packing be considered nec- essary, it may be confined solely to the tympanic cavity. As a rule, however, in the large majority of cases where it is desired to use a gauze drain, packing is entirely unnecessary and free exit should be maintained in every way for the dis- charge of the pus. Plain sterilized, iodoform or borated gauze is most frequently employed for this purpose, and in bone cases iodoform gauze is usually to be preferred, while in those cases where the osseous walls are not involved, it is more satisfactory to use the sterile gauze alone. Both bichloride and iodoform gauze will occasionally irritate the dermal lining of the canal, especially in children and young adults, and when such is the case the other varieties of gauze must be substituted, or some other of the various iodine- bearing antiseptic powders may be rubbed into the meshes of the gauze and an efficient substitute thus will be obtained. Pain in some few individuals may necessitate some atten- tion for a few days after ossiculectomy and curettement. It may be the result of two causes, one which has been men- tioned, that is, retention of blood clots or pus as a result of improper application of the dressings, and which is readily 174 Suppuration of the Middle Ear. relieved by their temporary removal, while in not a few ner- vous individuals considerable pain or distress may be com- plained of from the traumatism to which the tympanic cavity has been subjected. The mere cleansing of the ear in itself will often be sufficient to remedy this annoyance, while in other cases, where it is more or less persistent, lightly dust- ing the tissues with orthoform powder will benumb the ex- posed nerve endings and often give complete relief. At the most, the pain only persists for a few days after the opera- tion and then ceases spontaneously, but if it should persist for a week or more, one is warranted in believing that new areas have been infected and that an acute inflammation is present, or that there is a small pocket of retained purulent secretion which should be located and treated accordingly, this being especially so when other symptoms, as a marked rise in temperature, are also present. If some of the minor operations through the canal have been performed and the patient is in good physical condition, it is not necessary that any special attention be paid to his general health, but when ossiculectomy has been performed, and especially when the tympanic walls have been curetted, general constitutional treatment is frequently absolutely essential. In children and young adults the syrup of the iodide of iron seems to be very valuable, but the treatment used in any case, as far as the general health is concerned, must depend entirely upon the conditions present. After the minor operations through the external canal, such as enlarging a perforation or making a second perfora- tion in the membrana tympani, it is not necessary that the patient should be kept under any especial care during the first day following operation, but when an ossiculectomy has been performed or the walls of the cavum tympani curetted, it is best that the patient be kept in bed for several days fol- lowing the operation. As a rule the patient should be kept Operations through External Auditory Canal. 175 away from his occupation for a week following such opera- tions and for the first day or two he should be kept in bed, the recumbent position favoring drainage from the ear oper- ated upon. When the inflammatory symptoms become prom- inent, following this operation, it is advisable that the patient remain in bed or in a recumbent position until the tempera- ture returns to the normal, but in a not inconsiderable number of these cases no ill effects at all follow operation, and while the patient in such cases should not be confined to bed, yet it is better that he should avoid any fatigue or excitement during the first week after operation. It is also advisable after such operations that the diet should be re- stricted as far as possible, and while it may not seem to concern the aural affection, yet as a rule it is always advis- able to keep the bowels open in such cases as a part of the routine after treatment. The length of time before the purulent discharge ceases depends entirely upon the extent of the morbid process in the tympanic cavity and the thoroughness with which the affected tissues are removed. In minor cases, where the lesions are but slight, the discharge usually ceases imme- diately or at the most a few days after operation, but in those cases where the ossicles have been removed and the osseous walls curetted, the duration of the discharge will depend upon the complications which arise, the resistance of the tissues and the virulency of the middle ear infection. In those cases where the osseous lesions are not prominent, the discharge, as a rule, ceases in from one to two months after operation, but in cases where the tympanic walls are involved to any considerable extent, it may take a much longer period before the suppuration has entirely disappeared. In those cases in which successful results are. obtained, usually after a long period of after treatment, the tympanic mucosa assumes a dermoid appearance and its functions as a mucous membrane 176 Suppuration of the Middle Ear. are gone. This desirable result, which is always to be looked for in those cases in which the suppuration has ceased, may be enhanced by allowing the small segment of mem- brana tympani to remain after excision which is situated at the lower segment of the annulus tympanicus, as in this posi- tion it will usually become attached to the promontory wall which is situated directly opposite to it and growing here, the epithelial surface will form a nidus from which the walls of the tympanic cavity will gradually undergo a dermoid transformation and a nonsecreting surface will line the tym- panic cavity, so that as long as this remains intact the patient will no longer be subject to discharge from the middle ear, and in all cases of chronic suppuration where it is necessary to eviscerate the tympanic cavity, this should be the object to be attained. PART II. OPERATIONS UPON THE MASTOID PROCESS. 13 177 CHAPTER I. ANATOMICAL AND SURGICAL LANDMARKS. '79 ANATOMICAL AND SURGICAL LANDMARKS. As in many cases of chronic suppurative otitis media which seek operative measures for the relief of the puru- lent discharge, the morbid process is no longer confined to the tympanic cavity, including the attic, but has extended through the aditus and antrum to the mastoid cells, it is essential that the entire diseased area be obliterated to obtain a successful result. The mastoid operation or any of its various modifications may be necessitated for acute inflam- mation of this region, for the relief of tympanic complica- tions either intracranial or not, for the acute exacerbations of a chronic inflammation which has previously remained quiescent, or it may be performed both as a preventative of serious mischief from the aural lesion and directly for the relief of the chronic suppuration in which the various opera- tive procedures described in the previous chapters have failed to produce the expected relief, or in which operation through the external auditory canal is contraindicated by symptoms suggestive of an extension of the lesions which cannot be eliminated by the lesser surgical procedures. It is the latter with which we are here concerned, that is, the oper- 181 1 82 Suppuration of the Middle Ear. ative treatment through the post-auricular route for the amelioration or cure of the chronic suppurative otitis media. As the failure to obtain satisfactory results by operation through the canal is often the result of the extension of the tympanic suppuration to the mastoid interior by way of the antrum, it is with this latter space that operative measures for the relief of the suppuration must be concerned, and in considering the anatomical and surgical landmarks inti- mately concerned with operation upon this region, one must always have in mind the location of the antrum as a basis for safely removing the diseased tissues and as a guide after it has been opened for the further extension of the operative field. In relation to the tympanic cavity, the antrum should be considered as an extension posteriorly of the epitympanic space or vault of the tympanum, and when studied in this aspect, it is as much a part of the tympanic cavity as is the attic or any other portion, sharing in its pathological changes and on account of its mucous lining being continuous with the mucoperiosteum of the tympanum, it is in connection with the aditus, an integral part of the former chamber. As it is always that portion of the temporal bone first involved in the extension of the suppurative inflammation in its course from the tympanum to the mastoid cells, it usually becomes infected at a very early period, and as it is connected with the tympanum proper in its anterior aspect by the very small aditus, the retention of purulent secretion in the mastoid cells is thus greatly enhanced. The length of the aditus varies from 3 to 4 millimeters, and it is placed directly oppo- site the opening of the Eustachian tube in the tympanic cav- ity. The antrum in its posterior aspect is in intimate com- munication with the pneumatic cells of the mastoid process, this relation being so close that this cavity has been com- pared to a hub around which the cavities of the temporal EXPLANATORY NOTE TO PLATE XVIII. 8 This plate shows a type of a normal temporal bone with a pronounced convexity of the mastoid process. i, Stylo-mastoid process; 2, digastric fossa; 3, mastoid process; 4, supra-meatal spine ; 5, linea temporalis ; 6, squamous plate ; 7, glenoid fossa ; 8, zygomatic process ; 9, osseous external auditory canal. 184 PLATE XVIII Anatomical and Surgical Landmarks. 185 bone revolve. Topographically the antrum is irregular in shape as it passes backwards from the attic, and instead of possessing the somewhat compact walls of the latter cavity, its osseous surroundings are more cellular in structure. In relation to the external semicircular canal which assumes a somewhat important position in operations here, the antrum extends behind and above it. The constant presence of the antrum renders it of the greatest importance in the perform- ance of the various mastoid operations, and while other sur- gical landmarks may be absent or indistinguishable, the antrum is practically always present. A few observers have been unable to locate it in a small number of cases, but the studies of Birmingham show that its presence can be de- pended upon, as in one hundred skulls which he studied in this relation, the antrum was found to be absent in but one, in which the mastoid was solid and entirely free from pneu- matic structure. Its size, while usually constant, yet varies to some extent with the nature of the mastoid structure, as when the cellular system is pneumatic here the antrum is large, while the reverse is found the denser the structure of the former. From the studies made by the author quoted, the average length of this cavity was found to be from 12 to 15 millimeters, its width about 7 and its breadth from 8 to 10 millimeters, and he also found that the length of the tegmen antri extended from 3 to 6 millimeters above the upper margin of the external osseous canal, a point which becomes of much practical importance in its relation to sup- purative changes in this region. In relation to the external surface of the bone, its posterior aspect is placed nearer the surface than is the tympanic cavity, and in those cases where the cavity has become enlarged to any degree from the ex- tension of pathological changes from the tympanum, and especially when cholesteatoma is present, this factor becomes of great surgical importance, as in removing the posterior 1 86 Suppuration of the Middle Ear. and upper wall of the external canal, the antrum being under these circumstances so closely brought into relation with the canal, it is apt to be opened at but a slight depth from the surface, while usually it remains undiscovered until the far angle of the postero-superior portion of this wall has been reached. Above, the antrum, with the attic and aditus, is separated from the cranal cavity only by a thin bony roof, and opera- tive measures here must be most carefully guarded, both on account of the natural thinness of the tegmen and also on account of the frequency with which dehiscences are found ; Burkner, as quoted by Politzer, having observed this condi- tion of a defect in the osseous roof one hundred and sixty- seven times in a study of seven hundred and sixty-five cases. In relation to external landmarks, the antrum varies to some extent as regards its position during the growth of the indi- vidual, so that the landmarks later to be described alter their position in relation to the external auditory canal by grad- ually occupying a position inferior and posterior to it. Irre- spective of the age of the individual, however, the antrum remains inferior to the linea temporalis, and superior and anterior to the squamo-mastoid suture. In the child or young adult, however, these landmarks are not always suffi- ciently defined as to be available for operative purposes, but in the adult it is usually possible to clearly ascertain their presence and use them as guides for the opening of the antrum. In the vast majority of cases (see plate XVIII), the suprameatal spine is a constant landmark, and in the excep- tional cases in which this is not present, as pointed out by Politzer, the superior pole of the ellipse formed by the ex- ternal meatus, must be used as a basis for working down to the antrum. Usually at, or somewhat before, the age of puberty, the antrum corresponds to a horizontal line drawn EXPLANATORY NOTE TO PLATE XIX. 5' 3 A sagittal section of the mastoid process and tympanic cavity showing the rela- tions of its nerves, muscles and ossicles. (An original drawing after Hirschfeld.) i, Stapedius muscle; 2, stapes; 3, membrana tympani ; 4, tensor tympani ; 5, facial nerve ; 6, large superficial petrosal nerve ; 7, lesser superficial petrosal nerve ; 8, chordi tympani nerve; 9, Gasserian ganglion; 10, lenticular ganglion. 188 PLATE XIX Anatomical and Surgical Landmarks. 189 through the spina, and instead of altering its position in relation to the latter, it is quite fairly placed behind it at a distance of from 5 to 7 millimeters. As pointed out by the author last mentioned, the aditus connecting the tympanic cavity with the antrum has an average length of from 3 to 5 millimeters, it is usually 3 millimeters high and from 3 to 4 millimeters in depth, and as it forms the vestibule, as it were, of the antrum and bears an important relation to the horizontal portion of the Fallopian canal and horizontal semicircular canal, it plays an important role in suppurative conditions here. As the attic or epitympanic space becomes a factor of considerable importance in the surgical treatment of chronic suppurative conditions of the tympanum, the most important feature of its anterior wall should be borne in mind in operating here, that is, the delicate lamella of bone lying between the osseous walls of the Eustachian tube and the internal carotid artery, the walls of the former being con- tinuous for a short space with the latter, and inasmuch as it is generally essential in performing the radical operation to curette the tympanic opening of the tube, one should be careful in observing this close relationship. As usually con- sidered, the attic consists of that portion of the tympanic cavity superior to a line passing through the short process of the malleus and containing the head and neck of the mal- leus and the short process and body of the incus. The rela- tions of the attic and its walls have been already pointed out, but it may be mentioned here that its posterior wall is almost entirely comprised by the aditus, of which the superior por- tion is, as a rule, larger than the base, the height of the entrance from the tympanum being from 5 to 6 millimeters as an average. In those cases where the removal of the carious and necrosed tissue cannot be successfully performed through the external auditory canal, the knowledge of the relations between the attic, aditus and antrum is essential to 190 Suppuration of the Middle Ear. successfully treat the morbid process by operative proced- ures, especially in those cases where it is not desired to reach this region by way of the mastoid route, but in which Stacke's operation is more preferable by entering these chambers via the enlarged external auditory canal. From time to time various evidence has been brought forward in an endeavor to prove that the nature of the cell groupings in relation to important structures can be foretold by the external appearance of the mastoid exterior, or by the shape and configuration of the cranium, so that in operating upon the mastoid region one can avoid the lateral sinus, etc. It is very well proven, however, that we can obtain little or no evidence of any practical value in this way, except that occa- sionally some minor points may be surmised, as for instance in those cases where the mastoid process is quite large one may as a rule expect to find the pneumatic spaces separated by very thin osseous septa, with the spaces themselves larger than normal, although this is by no means invariably the case. Okade has carefully studied this aspect of the subject, and, as it is of great importance in relation to the surgery of mastoid infection from chronic aural suppuration, his results are well worthy of careful examination. He found that the anthropological form of the skull offers no trustworthy evi- dence of the presence or absence of the so-called dangerous temporal bone, that is, one characterized by a short distance between the transverse sulcus and the point of operation in endeavoring to reach the antrum. This variety of temporal bone, however, is found more frequently on the right than on the opposite side and more often when the mastoid process is small, while most important in this respect is the forma- tion of the mastoid, as this dangerous condition has been found to be present in those bones where the plane of the mastoid forms an angle with the axis of the external audi- tory meatus. In many respects this bone resembles the mas- Anatomical and Surgical Landmarks. 191 toid process of an infantile type, in which there is always a close approximation of the transverse sulcus to the operative field, and as essential points in recognizing this condition as far as such is possible, one may be led to suspect the dan- gerous proximity of the sinus when operating on the right side, if the mastoid process is unusually small, both in its external and perpendicular dimensions; if an infantile type of process is present; if the patient is below the age of pu- berty ; if the suprameatal spine is markedly inclined towards the median side ; and finally, one should expect this condition more frequently in women than in men. Of some usefulness in selecting a site for entering the mastoid process to reach the antrum as the initial point, one may seek for the depression in the bone immediately above and behind the suprameatal ridge, and when entering through this area the removal of the bone in a direction inward, down- ward and slightly forward will present an easy and direct route to the antrum. This space of which further mention will be made in describing the variations of the surgical landmarks in the child may be perforated by numerous fora- mina containing vascular twigs and bearing a close relation- ship with the antral space, as it very probably owes its origin to changes taking place in the development of the latter. The vascular zone varies to a marked degree in different individuals, and when not well marked may be represented by a single sinus-like depression with the minute foramina perforating its base towards the mastoid interior, or it may again present itself as a prominent cup-shaped cavity filled with a varying number of openings like a sieve, and of such a size that the mucosa of the pneumatic cells of the mastoid is practically brought into direct communication with the periosteum on the exterior of the bone. In very young children this relationship is very close, the depression then being designated as the "spongy spot," and it is in so inti- 192 Suppuration of the Middle Ear. mate connection with the antrum that it is separated from it only by a delicate layer of sieve-like osseous tissue, readily broken down and exposing the latter by but the slightest force. In selecting a point of election for opening the antrum, Macewen's triangle will usually form a most reliable guide, as this operator found in four hundred and fifty temporal bones that his triangle was well defined in four hundred and twenty-six, while it was recognizable in twenty-two, making it for practical purposes an almost constant guide in such operative procedures. This area is located by its relations to the posterior and superior walls of the external auditory canal, and its position has been described by Bench as being formed by a horizontal line drawn tangent to the superior wall of the external auditory canal, while a second line is drawn vertical and tangent to the posterior wall, so that the point of intersection of the two lines will form the apex of the triangle, its base will be defined by the curved border of the meatus lying between the points of tangency of these two lines, and beneath the triangle thus outlined will be found the antrum. The extent of the operative triangle as regards safety may often be influenced by the size of the mastoid process, as it will usually be found to be the case that when the mastoid is small, pointed and narrow, the groove for the lateral sinus will be deeply placed, while the operative limits of this triangle will be contracted. While, when the reverse of this condition is found, that is, when the bone is blunt, rounded and broad in area, the triangle of election becomes correspondingly increased in its diameters, and the sinus, being placed further away from the posterior canal wall, allows a larger area for safely opening the antrum. The suprameatal spine or spine of Henle offers a most reliable guide and is one of the best landmarks in opening the mastoid process in order to accurately and safely enter EXPLANATORY NOTE TO PLATE XX. A sagittal section of the mastoid process on a plane with the facial nerve. The course of the carotid artery through the petrous portion of the temporal bone is shown. (An original drawing after Hirschfeld.) i, Opened aquseductus Fallopii ; 2, fenestra ovalis ; 3, hiatus Fallopii; 4, point of emergence of the superficial petrosal nerve ; 5, cerebral surface of the petrous portion of the temporal bone ; 6, osseous opening of the Eustachian tube ; 7, promontory ; 8, fenestra rotunda; 9, mastoid cells; 10, internal carotid artery. 194 PLATE XX Anatomical and Surgical Landmarks. 195 the antrum. It is situated as a more or less prominent osseous plate or projecting surface, superior and posterior to the upper and back wall of the external canal, imme- diately below the supramastoid ridge, and as a rule, it is curved in nearly a concentric position in relation to the cir- cumference of the aural opening, with its upper portion being slightly placed more anteriorly than its lower. In some cases it projects but very slightly above the osseous level, and is thus rendered somewhat difficult of localization until the soft tissues have been pushed well back over this area and by drawing the handle of the scalpel over the exposed bone, the elevation of the spina can usually be located in practically all cases. While in connection with the depression of the bone immediately above it, the spina is probably our best guide, yet some differences of opinion exist as to its constant presence. Kiesselbach in one hundred temporal bones examined found it eighty-two times; Schultze one hundred and nine times in one hundred and twenty tem- poral bones; while Lemoir in two hundred adult skulls which he examined for this purpose, found it was absent in but one, although in twenty instances it was not well marked and required some care to ascertain its presence. As has been stated elsewhere, "the spine of Henle will seldom fail and will never mislead," and if in looking for it after the primary incision has been made by carefully going over the mastoid surface in this particular location, one will be able by making the opening in the bone on a horizontal line from 4 to 8 millimeters posterior to it, to obtain a route parallel to the external canal and slightly inclined upward, that will reach the antrum at a depth of from 10 to 15 milli- meters in the vast majority of cases operated upon. While the location of this landmark practically never varies in the adult temporal bone, as regards its value as a surgical guide, its size and appearance does vary, however, in many in- 196 Suppuration of the Middle Ear. stances, as in addition to its physical characteristics already mentioned, it may be represented by a flattened projection of bone separated from the supramastoid ridge by an aver- age distance of 6 millimeters. Or again, it may project as a sharp-pointed spine springing backwards and upwards from the auditory canal, and thus marking the posterior margin of the meatus, so that in these cases its detection presents no difficulties at all, and the point of election for opening the bone just posterior to it can be ascertained at a glance. As pointed out by Kiesselbach, this osseous spine at the lower margin of the perpendicular part of the squama is only found on adult temporal bones. Just behind the su- prameatal spine, and therefore in close relation to the posi- tion where the planum mastoideum passes into the posterior wall of the external canal is the fossa which Yearsley believes to be always present, although it may be a mere dimple on the surface, and which he considers as a more accurate guide than the former. In relation to the floor of the middle cerebral fossa, the spine of Henle is at the nearest point about 6 millimeters below it, and one can be fairly certain in operating here that the cranial cavity is never lower than the spina, as in one thousand skulls examined in reference to this point, Randall found it as low as the spine in but five. The length of the postero-superior canal wall should also be considered in estimating the probable depth of the Fallo- pian and horizontal semicircular canals. The length of the canal varies to a considerable extent in different individuals, its average length, measured from the spine of Henle, being from 12 to 17 millimeters. For practical purposes, the depth of the overlying soft tissue must also be taken into account, as they usually double this distance. For this reason, there- fore, one is very apt to go astray when the soft parts are in situ, and in all cases where it is desired to open the antrum the measurements as to the depth to which one can safely EXPLANATORY NOTE TO PLATE XXI. An anatomical plate showing the inner surface of the temporal bone and exposing the internal ear. (An original drawing after Hirschfeld.) i, External auditory canal ; 2, ossicles ; 3, vestibular cavity ; 4, stapes ; 5, superior semicircular canal ; 6, posterior semicircular canal ; 7, horizontal semicircular canal ; 8, cochlea ; 9, internal auditory canal. 198 PLATE XXI Anatomical and Surgical Landmarks. 199 penetrate into the mastoid interior in order to reach the antrum should be made from the suprameatal spine or the opening in the bone at this point. Broca states that the depth of the antrum depends on the age of the subject and also varies at an equal age in different individuals. In in- fants it is but 2 to 4 millimeters from the mastoid cortex, and is readily penetrated by slight pressure with a curette over the spongy spot. As a result of this variation in depth, he states that if the rule is laid down to cease oper- ating if the antrum is not found at 5 or 6 millimeters (Polit- zer), at 20 millimeters (Noltenius), or at 25 millimeters (Schwartze), one risks missing an antrum which possibly is present. Holmes, in measurements made to determine these points, the spine being used to determine the fixed point from which the measurements were made, found the distance from the suprameatal spine to the facial nerve to be 15 millimeters; to the horizontal semicircular canal 16; to the posterior semicircular canal 18; to the foot plate of the stapes 22; and to the end of the short process of the incus 16 millimeters, and based upon these studies he further states that the only safe guide as to the extreme distance that we may penetrate, is the distance from the spine to the postero-superior margin of the drum membrane, which varies but little from 15 millimeters. In a recent study of thirty temporal bones in reference to the antrum, Kerrison measured the thickness of the osseous tissue sepa- rating the antrum from the cortex, and was able to demon- strate three facts. He found that in different specimens much greater variations existed as to the length of the bony meatus than are usually considered in most text books. The depth of the antrum was always less by actual measurements than the postero-superior canal wall and that the depth of the antrum rarely, if ever, exceeds 15 millimeters. In these bones, the length of the posterior canal wall varied from 200 Suppuration of the Middle Ear. 12 to 1 8 millimeters, and the depth of the antrum from 6 to 15 millimeters, and as a result of these figures, he suggests that in operations on the mastoid, the antrum should always be approached from the nearest point upon the cortex, which in the great majority of temporal bones is the small triangu- lar space just behind the spine of Henle. This point not only furnishes a guide to the site of the antrum, but gives fairly accurate data as to the depth beyond which it is not safe to proceed. The depth of the antrum is always less than the length of the postero-superior wall of the meatus, and finally in attempting to expose the antrum, the depth of 15 millimeters should be the extreme limit of safety. Two important structures by their location must always enter into the most serious consideration in the performance of a mastoid operation, namely, the facial nerve and the lat- eral sinus, the position of which influence to some extent the methods employed in entering the antrum. Inasmuch as the relations of the external semicircular canal are, as regards the treatment of chronic aural suppuration, in intimate con- nection with the Fallopian canal, these two structures may be here considered together. After the prominent facial canal has formed the upper border of the oval window, it can be recognized as it passes a few millimeters anteriorly to become blended with the geniculate ganglion, where it no longer pos- esses surgical interest in this connection, as it becomes pro- tected from surgical traumatism by its deeper penetration into the petrous portion of the temporal bone. At this point the nerve is brought into relation with the tensor tympani muscle, the former lying to the inner side of the muscle and its par- tially formed osseous canal. Posteriorly to the oval window, the nerve assumes great importance on account of the danger of wounding it here during the various procedures of the post-auricular operation. With a well-marked curve from this point, the nerve then descends so that it passes but a Anatomical and Surgical Landmarks. 201 millimeter or so from the posterior edge of the tympanic annulus, and then again loses its importance as a surgical landmark as it passes in a vertical direction to its exit from the bone, through the stylo-mastoid foramen. Both the facial and semicircular canals, by their projection, narrow the aditus at the point where the horizontal portion of the nerve passes directly in relation with the tympanic entrance of the aditus, immediately preceding its bend as it passes down- wards. As the position assumed by the nerve posterior to the margin of the tympanic ring becomes vertical, the nerve enters the anterior limits of the mastoid process, where, as it descends downwards, it passes somewhat outwards and backwards, so that it is in intimate relation with the posterior wall of the external canal at the junction of the middle and lower third. As the facial nerve in this portion of its course passes through dense, compact osseous tissue, inasmuch as this part of the temporal bone forms here the lower portion of the posterior wall of the tympanum and the lower and posterior walls of the external canal, the so-called facial spur is found at this point and in doing the radical operation it acts as a danger mark, as it must be avoided in order to pre- vent injury to the nerve. The bony canal at this point is exceedingly dense in the normal state and is deeply situated, unlike the elbow of the horizontal portion of the nerve which is often very thin and sometimes deficient, so that if care be used by protecting it, one can usually avoid wounding the nerve in this situation, if this area be not trespassed upon. As a valuable indication in avoiding the nerve here, is the appearance of a line of dense bone in the operative field, and when such tissue is encountered at any position in the course of the facial nerve, one should be very careful in the employment of the chisel or sharp spoon. This is especially so in removing the wall of the aditus and in performing this part of the operation, it is always wisest to use the chisel at 202 Suppuration of the Middle Ear. such a height that the elbow of the canal containing the nerve will not be damaged, this usually being accomplished, if the excavation of the mastoid inward is not allowed to pass below the level of the suprameatal fossa or the spine of Henle, so that the nerve will then not be subjected to trau- matism, although in some cases where the osseous destruc- tion is extensive this is not always possible. Randall states that the facial canal is never less than 16 millimeters from a point 5 millimeters behind the spina and its anatomical guide is the polished boss or bony prominence on the inner wall of the antrum which marks the protuberance of the hori- zontal semicircular canal and the downward curving con- vexity of the facial canal, and from this point its descent is exactly vertical. He further states that the method of operation should be such that it furnishes a perfect guard to the facial nerve, and if possible, this should be obtained by the natural structures, rather than by any instrument which may perpetrate the injury which it is devised to pre- vent. If the operation is done from a point near the an- nulus, it is feasible to open the aditus from the canal with great security to the nerve, as the margin of the Rivinian segment remains between it and the chisel as a bridge against which we can safely chisel until it is too delicate to afford further protection, when it is easily broken away by outward traction with the spoon, so that the opening into the antrum and attic needs but such additional enlargement as the con- dition of the carious process demands. When the mastoid and tympanic cavity are to be eviscerated, he finds it more convenient to open the mastoid first and to remove the pos- terior wall of the meatus between the canal and mastoid cavities, antrum and attic, by rongeur or chisel, working from without inwards, the same bony margin being pre- served as a guard until the last steps of the procedure, will bridge the gap directly over the nerve. Leading apparently EXPLANATORY NOTE TO PLATE XXII. 1 This plate shows the external surface of the temporal bone of the new-born infant. Observe the flat character of the bone due to the absence of the angle between the annulus tympanicus and the squamous portion. Also the absence of the mastoid process and the relative disproportion between the size of the drum membrane and the bone itself. i, Squamous plate; 2, zygomatic process; 3, glenoid fossa; 4, handle of the malleus ; 5, membrana tympani ; 6, annulus tympanicus. 204 PLATE XXII Anatomical and Surgical Landmarks. 205 outward from this, the ridge constituted by the anterior wall of the mastoid can be cut down as far as the middle of the annulus and thence outward in a steep slope which can approximate the vertical course of the descending part of the facial nerve. The descending portion of the nerve, which is therefore the most important part from the surgical standpoint, is almost universally perpendicular and occupies an almost constant relation to the inner end of the auditory canal, and as shown by Randall in a series of one hundred skulls, practically no variations in its course were found. Jones, in studying the anatomical relations of the facial nerve in relation to the mastoid operation, states that if we bear in mind the constant relation of the nerve to the tym- panic ring, we shall not be led to think in bones in which the tympanic ring and mastoid process are more or less rudimentary, that the facial canal is further in than it really is, independently of measurements from the surface. As Stiles has shown, the nerve in young children is ex- posed to danger at its exit from the stylo-mastoid foramen, even from the knife used in incising the soft parts. In adults the angle of inclination of the facial canal, the point at which it intersects the plane of the tympanic ring and the relation of its lower part to the highest point in the curved floor of the external meatus, enables one to tell how much of the osseous wall can be safely removed in the Stacke- Schwartze operation. As the outward and backward incli- nation of the facial canal brings it into relation in its lower half with the petrous or deeper mastoid cells, a knowledge of the relation of the nerve posterior to the highest point of the meatal floor is of value when a sinus has formed be- tween the meatus and mastoid cells. While the proximity of the nerve to the inner part of the tympanic ring and the floor of the iter exposes it to danger during the introduction of Stacke's protector, either by its point entering the sinus 206 Suppuration of the Middle Ear. tympani instead of the iter, or by backward pressure on the floor and inner wall of the iter. Broca, in some recent studies, states that the horizontal part of the facial canal, with its elbow, that passes under the threshold of the aditus is protected only by a lamella of bone that is sometimes ex- tremely thin. If in a child we seek the antrum, which is high, the opening is absolutely without danger to the facial nerve, and if when the antrum is exposed we demolish the outer wall of the aditus, the nerve is secure from risk, pro- vided that in making the inferior cut with the chisel, we incline the instrument a little upwards. In the adult antrum, however, behind the meatus the inferior extremity is there separated by the elbow of the facial. On an average Nol- tenius found the distance separating the spina and the facial canal to be 13 millimeters in depth. The safest average to take, however, is 10 millimeters, while the best precaution is not to make the opening too low in the bone, but as soon as the aditus comes into view one is master of the situation, as the location of the facial nerve is then known. To deter- mine these relations of the facial nerve, Joyce measured thirty bones so as to find the exact distance from the surface to the nerve in the location usually selected for the mastoid operation, and each bone was drilled vertically from the sur- face to the aqueductus Fallopii in three places, first, at a point immediately behind the center of the external audi- tory meatus; secondly, at a point immediately behind the upper border of the same; and thirdly, at a point above the center of the meatus. From the first point the average dis- tance to the nerve was 16.75 millimeters; from the second 18.5 millimeters, with a minimum of 14.75, while from the last named position, the distance was 19.4 millimeters, with a minimum of 16.25. As a result of these investigations he concludes that the facial canal lies altogether in front of the mastoid, and that a drill sent straight in from any point on Anatomical and Surgical Landmarks. 207 the surface of the latter cannot injure the nerve. As meas- ured from the second position, the facial nerve is in 43.3 per cent, of cases more superficial than the external semicircular canal, while in the same percentage of cases this was re- versed, and in 13.4 per cent, both were the same distance from the surface. Thus the external semicircular canal cannot be taken as a guide to the depth of the facial canal. He also finds that the average distance of the facial nerve from the second point is slightly less than that of the external semicircular canal, and in removing the outer wall of the attic, this canal is in 91 per cent, nearer the third point than the facial; however, as it is 1.5 millimeters higher than the facial nerve, it is almost out of danger, besides it has a thicker covering of compact bone here in the attic than has the nerve. In addition to the points already mentioned as regards the horizontal semicircular canal, its position immediately back of the inner wall of the aditus and above the aqueductus Fallopii renders it fairly well protected from operative trau- matism, although it may sometimes be damaged if the mas- toid opening is continued beyond the level of the internal wall of the tympanum, but this should never happen in careful hands, and if a protector be placed here, it is practically im- possible to do the canal any harm. Even if one should not be accurately satisfied as to its location in any particular case, it is fairly well protected and offers considerable resist- ance to instrumentation by the thick and firm osseous tissue which surrounds it. The structure of the mastoid of necessity in this connec- tion assumes considerable importance in relation to oper- ations upon this portion of the temporal bone, and as a rule one may classify the processes under the three well- known divisions: the pneumatic (see plate XXIV), in which large cell spaces occupy the bulk of the mastoid and to 208 Suppuration of the Middle Ear. a greater or lesser extent communicate with one another and with the antrum; the diploic type (see plate XXV), in which the cells are very small and somewhat indepen- dent of each other; and the sclerotic variety, in which the bone is hard, compact and practically devoid of a cellular structure. In the oft-repeated and valuable studies of Zuckerkandl, in regard to this point, 36 per cent, of the temporal bones examined belonged to the first type, 20 per cent, to the second, and in 42 per cent, both of these types were present in varying degree. A thorough knowledge of the distribution and major variations of the mastoid cells is as essential to the proper appreciation of the pathology and surgery of chronic suppurative otitis as is a knowledge of the antrum or any other portion of the temporal bone, and it is only by a thorough understanding of their relationship and their extensive distribution that one can successfully remove the diseased tissue with any degree of safety in the larger number of cases of chronic tympanic suppuration in which operative measures are indicated. Before entering the inner structure of the mastoid process, one usually finds the cortex varying greatly in thickness, depending upon the age of the patient within somewhat indefinite limits, and also upon the nature and duration of the pathological changes present in the individual case. During early childhood it is usually very thin and may readily be penetrated with but little force, while in the adult it may vary in thickness from 2 to 5 millimeters or even more, especially in those cases where the inflammatory process has occasioned a great in- crease in the thickness and density of this tissue. The pneu- matic type of process varies greatly in the arrangement and extent of its cellular development, although in all temporal bones, irrespective of the size or number of the cells, it has been very clearly demonstrated that the mastoid cells are but annexes of the antrum. In some instances the cells are large EXPLANATORY NOTE TO PLATE XXIII. This plate shows the internal surface of the temporal bone of the new-born infant. Observe the rudimentary state of the mastoid process. i, Inner view of squamous plate ; 2, rudimentary mastoid process ; 3, incus ; 4, malleus ; 5, membrana tympani ; 6, annulus tympanicus. 210 PLATE XXIII Anatomical and Surgical Landmarks. 211 in number, irregular in shape, and to a great extent extend in various directions, while in other specimens, the mastoid process may be entirely or in great part composed of but one or two enormous cell dilatations, with or without smaller scattered cells in immediate relation to them. In cases of the former class the mastoid cortex is apt to be quite thin, while in the latter, it is even more so, and the large size of the cell or cells may cause it to have a much more convex surface than is usually observed. Especially may this be the case on the internal surface of the apex of the process. While the pneumatic cells may be very large, as just de- scribed, they do not necessarily communicate with each other or with the antrum by proportionally large openings, as it is often common to find in such cases that the communicating spaces are quite small. Where the larger spaces are numer- ous, they may extend from the antrum as far as the occipital bone posteriorly and embracing in great part the sinus and inferiorly they may reach well to the cortex of the apex, while above and in front, the cells may to a considerable extent surround the auditory canal and even extend well up to the temporal ridge. As to the extent to which the patho- logical process may be influenced by the cell development, the carious process may involve their walls, when numerous, as far inwards as the apex of the petrous portion of the tem- poral bone, and they may even surround the labyrinth, be in relation to the bulb of the jugular vein and part of the carotid canal. Broca classifies these cells into various groups, and says that only the true mastoid cells are situated below a horizontal line passing near the junction of the upper third with the lower two-thirds of the meatus. The squamous cells are in that part of the squamous bone which contributes to the formation of the posterior wall of the external meatus, while some of them form in contact with the meatus, the group of cells bordering it. These are 212 Suppuration of the Middle Ear. sometimes prolonged above and even in front into the root of the zygoma and above the temporo-maxillary articulation. The petrous cells occupy the base of the process above a horizontal line passing through the junction of the upper third and lower two-thirds of the meatus; in front they are limited by the arched premastoid -lamina, and behind they extend towards the lateral sinus, in front of which they may extend almost to the occipital bone. In some cases the an- trum may be hidden by a convex septum, and if the cell which is bounded behind by this septum is very large, one may think that the antrum has been opened, but search in the superior angle of this false antrum with the probe fails to find the narrow opening of the aditus, and by excavating below and under this lamella, the antrum is reached at the level of the spine of Henle. While the diploic type of mas- toid usually contains a few fair-sized pneumatic cells, yet its structure in great part is composed of numerous very small cells and presents the typical histological structure of diploic tissue. The third type, in which sclerotic tissue predominates, is usually associated in part with diploic tissue, and it seems highly probable that this variety of mastoid is responsible for its dense, ivory-like structure in many cases by gradual pathological changes, the entire mastoid process in such in- stances being smaller in size than the pneumatic type. In addition to these another type has been described in which the lower part is diploic and the upper pneumatic, or the posterior and lower part may be diploic, while the superior portion possesses a pneumatic structure. In exceptional cases aberrant cells may be present in the mastoid process, and from their unusual location they are apt to be over- looked, or remain entirely undiscovered, and if the seat of infection may seriously compromise the entire result of the operation. This condition is quite unusual, however, but is well shown in a case reported by Moure and LaFarella, in EXPLANATORY NOTE TO PLATE XXIV. An original anatomical section through the temporal bone. The pneumatic type of mastoid cells are shown. i, Large tip cell ; 2, pneumatic variety of cell ; 3, facial canal ; 4, inner surface of tympanum ; 5, aditus ad antrum ; 6, mastoid antrum. 214 PLATE XXIV k Anatomical and Surgical Landmarks. 215 which the mastoid process was cleaned out and all diseased tissue was removed down to the healthy bone and prompt healing took place. One month later, however, symptoms of meningitis developed, the patient died and autopsy showed that the cause of the trouble was an aberrant pneumatic cell filled with pus in the posterior part of the mastoid, above a plane passing through the upper border of the external meatus and one centimeter behind a line passing through the tip of the mastoid. This cell was completely separated from the operation cavity by a wall of healthy bone 0.5 centimeter in thickness and limited internally by the lateral sinus, while the entire operated area was found to be perfectly healthy. The squamo-mastoid suture forms a landmark of not in- considerable importance, as it forms one side of the triangle previously described in connection with the linea temporalis, and the external auditory canal, and while it is of necessity always present, it is frequently inconspicuous and not avail- able as a surgical landmark. When it can not be recog- nized by the finger, however, its location may sometimes be ascertained during the stripping of the periosteum from the bone by the furrow adhering very closely to this point and either a delicate white line left will enable one to recognize it, or it may be found by the shreds of periosteum which can- not be removed from this point. In the mastoid interior traces of the suture may also occasionally be found as a more or less well-defined osseous wall beneath the location of the furrow on the cortex and not infrequently limiting to some extent a single large cell or a group of smaller pneumatic spaces. The linea temporalis is a most important and usually con- spicuous landmark and one of the external anatomical points already described, that indicates a safe passage to the antrum and the avoidance of the lateral sinus. Of the three promi- nent landmarks in this region, that is, the temporal ridge, 216 Suppuration of the Middle Ear. the spine of Henle and the squamo-mastoid suture, the first is by all means the most constant and is the prolonga- tion backwards of the posterior root of the zygoma over the entrance of the external auditory canal. It is the most relia- ble guide that we have from the exterior of the bone to ascertain the level of the floor of the middle cranial fossa, for in the vast majority of individuals it is placed imme- diately inferior to this plane. That is in the majority of cases in which the post-auricular operation is performed, the fossa of the skull is placed at a higher level than the hori- zontal line through the upper wall of the osseous external canal, so that the location of the floor of the fossa is com- monly inferior to a plane passing through the temporal ridge. From studies made by various observers, the linea temporalis has been found to lie lower than the middle cerebral fossa in 80 per cent, of cases, while in 20 per cent, it is either slightly higher or on a level with it. Even in the child the temporal ridge is practically always appreciable and as it is so generally constant, it is of most important value in deter- mining the upper limits of the operative field, as under no circumstances should the bony removal be carried above this line for fear of unnecessarily entering the skull cavity. As it is almost invariably present, and is probably the most easily recognized of all the landmarks here, its value in a surgical aspect is of course greatly enhanced, and while it may pre- sent slight anatomical variations that may cause it to be on a line with the cranial floor or slightly above it, such are very rare and one may feel perfectly safe in considering it as a landmark that will be a safe guide. In the young child, the prominence of this ridge is due to the marked oblique angle between the auditory plate and the squama, but in some cases, instead of the squamous portion of the bone occupying an almost vertical position, it may be considerably inclined, and thus form an acute angle with the horizontal plane, so that Anatomical and Surgical Landmarks. 217 the linea temporalis overhangs the orifice to the external canal, and in operating may be mistaken for its superior margin. To avoid this error, the bony tissues in this region should be fully exposed by drawing the anterior flap of the soft tissues well forward and the landmarks clearly shown before the bone is at all opened, for if this be not done, and the temporal ridge in this unusual situation cut away in mis- take for the superior wall of the meatus, the opening will be superior to the antrum and the chisel will enter the middle cranial fossa. The venous relations of the mastoid and tympanic re- gions, aside from the lateral sinus, present but little of im- portance in operations here for the relief of chronic tympanic suppuration, when the various complications of mastoiditis are not considered. As it is not desired to touch in any way upon these latter features, it will therefore be unnecessary to occupy much space with this part of the subject, but it is desired to state that the inferior petrosal sinus receives a considerable number of small venous branches from the in- terior of the bone, and thus adds to the dangers arising from the transmission of infection. In addition to this, at various points, and especially at the petrosquamous suture where fibrous slips from the dura enter through the minute osseous clefts, vascular channels also enter and form a direct com- munication in this way, so that the interior of the mastoid and the cranial contents possess a quite intimate vascular association. As regards the mastoid cortex, one is apt to sometimes have annoying bleeding take place when the perios- teum is stripped up from the posterior surface. This results from severing the mastoid emissary vein, and while in the majority of cases the vein is small and of little surgical importance, yet in a few instances where the depression in the bone through which it passes is quite large and the vein also correspondingly increased in size, it may produce con- siderable bleeding and for a time prove most annoying. 218 Suppuration of the Middle Ear. Of the greatest importance in every mastoid operation, and that which causes the greatest concern to the operator, is the lateral sinus and its location in relation to the field of operation. There is probably no important portion of the temporal bone which is so uncertain or presents so many diffi- culties in determining its location as this sinus, and in per- forming even the simple mastoid operation there is no one part of the bone which causes the operator greater concern, or in which he is less able to formulate accurate rules for its avoidance than is this sinus. While many suggestions have from time to time been offered so that the operation may be safely conducted as regards the wounding of this vessel, yet they do not possess a great deal of value, and in opening the mastoid process we practically have no absolute guide that may be based upon the topography of the parts. Each case should therefore be conducted as if the sinus were directly in the position at which it is desired to enter the antrum and the operation should be performed with the knowledge that the sinus may be encountered at any step and due precau- tions should be taken accordingly. Not only does it vary as regards its position, but as pointed out by Randall, it also varies as regards its size, and as most of the blood of the superior longitudinal sinus usually flows to the right, the sinus of this side is often the larger and grooves more broadly and deeply, the temporal bone at the sigmoid sulcus, extending further forward and outward with its stronger curves. This factor is of no value, however, in render- ing the operation safer on the opposite side and he further finds that the space between the sigmoid sulcus and the antrum is actually and relatively smaller in the adult, but rarely exceeds 5 millimeters, while there is a distance of 10 millimeters between it and the posterior wall of the external canal. It is usually considered, and a study of a large number of temporal bone will show, that in the normal EXPLANATORY NOTE TO PLATE XXV. An original anatomical section through the temporal bone exposing the inner surface of the membrana tympani and ossicles. The diploic character of the mastoid process is shown. i, Roof of tympanum; 2, ossicles; 3, membrana tympani; 4, facial canal; 5, promontory ; 6, diploic cells ; 7, cerebral fossa ; 8, mastoid antrum ; 9, aditus ad antrum. 22O PLATE XXV Anatomical and Surgical Landmarks. 221 mastoid, when the cortex is thick, the osseous tissue is very apt to be thin over the tip and in the region of the digastric fossa, while in other specimens, where the mastoid process projects but little and is small in size, the lateral sinus will often encroach upon the antrum, but unfortunately there are many exceptions to this. When the sinus is very large and bulbous it comes in closer contact with the cortex and pos- terior canal wall, and the osseous tissue covering it in either of these directions affords but little protection when opera- tion is performed here, while in the diploetic type of mastoid the same conditions are very apt to be present. When the mastoid process is strongly developed and the pneumatic spaces well marked, there is comparatively little danger of encountering the sinus during the opening of the operative tract from the cortex to the antrum. On the other hand, where the bone is small and sclerotic, there is but a small bridge of compact osseous tissue between the sinus and the posterior canal wall, and when this condition exists in con- nection with the sinus .placed well forward, it is almost im- possible to avoid opening its osseous canal during operation. It is sometimes believed that a prominent temporal ridge indicates that the sinus is placed further forward than usual, but this is so unreliable that it is of no practical value. In a general way, the sinus may present either one or two well-marked abnormalities as regards its position ; its groove may be unusually deep, and when this is found, the enlarge- ment of the channel lessens the thickness of the osseous tissue separating it from the wall of the antrum, or the groove may be placed much more anteriorly than usual, so that the sinus is brought immediately internal to the antrum, or even in rare cases in front of it, so that the cavity of the antrum will be narrowed from without inward and its inner wall will assume a more dangerous significance than if this was not the case. Normally the sinus lies behind the antrum, but in another 222 Suppuration of the Middle Ear. small group of cases the bend in the sinus may be so short that an acute angle is formed, which again brings it into extremely close relation with the canal wall and even so near the surface of the mastoid process that it is impossible to enter the antrum at the usual point. The more one ap- proaches the tip the less danger there is of wounding the sinus, while as a rule the most dangerous area is placed directly back of the antrum, but unfortunately in all these variations, external measurements are of little or no value in ascertaining this in advance of operation, and one must always keep in mind when operating here the variations in size and position that may be encountered, so that it is advisable to make the opening through the cortex of the mastoid as near the posterior wall of the external canal as possible, as a measure of precaution, and then after the cells are first entered one is enabled to obtain a fair idea of the relations of the parts, and can then enlarge the field of oper- ation to the size required with a considerable degree of safety. That the sinus may present such serious variations is well shown in a case reported by Powers, in which, during the first step of the operation, it was encountered, and the operation had to be abandoned. The autopsy later showed that the sigmoid sulcus, instead of turning sharply and form- ing only a slight groove between the pars petrosa and the squama, extended so far ventralwards that with the exception of a slight bridge of bone in the anterior aspect of the ante- rior pyramid, these two portions were completely separated and the sinus extended above the mastoid crest for some 0.7 centimeter ventralward to the external auditory meatus and caudal ward to a point within 0.7 centimeter from the tip of the mastoid. In opposition to this view of the changes in the position of the sinus rendering it so liable to injury during the performance of the mastoid operation, Hart- mann in one hundred preparations only found two in which Anatomical and Surgical Landmarks. 223 trephining would injure the sinus, while Ricord found only one case in which this danger existed, and in what he calls an "extreme case," a distance of 12 millimeters still sepa- rated the sinus from the posterior wall of the external meatus and he further concludes that the posterior half of the mas- toid is dangerous on account of its vicinity to the lateral sinus, but the danger diminishes in proportion as one leaves the base to approach the summit of the process. Of the various theories that have been advanced to deter- mine the location of the sinus previous to operation, it has been suggested that it can be accurately located by applying a tuning fork and stethoscope to the temporal bone. With the bell of the stethoscope placed over the mastoid process, the handle of a vibrating tuning fork is placed against the head one inch behind the mastoid and the fork is gradually moved closer to the stethoscope, so that a$ soon as the border of the mastoid is reached a decided increase in the volume of the fork takes place. Like various other methods for determining the site of the sinus, this method unfortunately has proven of little value, and cannot in any way be de- pended upon. Amberg, in studying this highly important question, states that displacement of the lateral sinus is due to and indicated by asymmetry of the skull. No skull is entirely symmetrical, the -right side as a rule being smaller than the left, and as on the smaller side the sinus is dis- placed forward, so the sinus is displaced more frequently on the right side. He gives the following signs to indicate that the sinus is displaced forward : ( I ) The eye is somewhat higher on the side on which the sinus is displaced. (2) The nasal septum is pushed towards the opposite side; there is a prominence on the opposite side ; the tip of the nose is turned towards the side on which the sinus is forward and the aper- ture pyriformis is larger and stands somewhat higher on the same side. (3) The hard palate on the same side is higher 224 Suppuration of the Middle Ear. and narrower. (4) The incisor is placed a little more towards the side on which the sinus is displaced forwards. (5) The occipital and parietal bones are pressed inwards on the same side and pushed outwards on the opposite side. (6) The greater the extent of the planum mastoideum and the more perpendicular it stands on the outer meatus, the less strongly the sinus is developed. The planum forms an angle greater than a right angle with the meatus. In seven- teen bones he found the thickness of the wall of the sinus to vary from 2.5 to 10 millimeters, with an average thickness of 5.75 millimeters. As the topography of the temporal bone and its land- marks vary to a considerable extent in the child from that of the adult bone, it is essential to bear in mind these varia- tions when operating in the young, as they influence not only the direct method of opening the mastoid, but also the patho- logical changes which take place here following chronic sup- purative changes in the tympanic cavity. As with the adult, the depth of the middle cranial fossa of course varies, but even in the child one can always be positive that it lies above the supramastoid spine. At birth the external wall of the epitympanic space is in the same position as occupied by the inferior wall in the adult, the variations at this point result- ing from the changes assumed by the direction of the pars squamosa during the developmental period. As a result of this, the vault of the tympanic cavity is readily entered imme- diately above the superior attachment of the membrana tym- pani, but in making the incision through the superficial soft tissues in performing any post-auricular operation at an early age, great care must be taken not to make too much pressure, as the knife may pass through the squamous suture into the cranial cavity, as this suture does not become closed completely until a later period, and always presents a large opening in the osseous structure which is filled with soft 'Anatomical and Surgical Landmarks. 225 fibro-cartilage. For the same reasons gentleness should always be exercised even in laying back the integument and periosteum in making the anterior flap. The "spongy spot," which has previously been mentioned and which is present in all young children, is situated over the exact level of the antrum, but at birth it is somewhat above this level, then later it becomes above and in front, so at a still later period this vascular area is in relation posteriorly with the supra- meatal spine, and when this relationship becomes well marked the spina becomes valuable as a landmark of surgical im- portance. When one removes the cortex at this level, that is, over the area above and behind the external meatus, the antrum is very rapidly reached and in the first two years of life it is situated but a slight distance beneath the surface, so that the slightest pressure with the instrument employed over the perforated vascular area immediately above it will show the antrum at once. Both in the child as well as in the adult it is never advisable to remove the mastoid cortex as a primary step of th operation at a higher level than the spine of Henle, and in order to remain within the zone of safety, it is always essential to enter the mastoid just pos- terior and close to this spine, so that the antrum will be en- tered with a minimum of danger, and then if it is desired to expose the attic of the tympanum, the external table may readily be removed in a forward and upward direction. As the osseous auditory canal is not present at an early age, it is necessary to bear in mind that the squamous plate occupies a much more horizontal position, and that the fibrous canal is thus attached to its outer aspect at a dif- ferent angle than that which is seen as the child becomes older, or as adult life is reached (see plates XXII and XXIII). As a result of the canal being attached to the squama along its superior aspect, the attachment of the auricle to the bone is situated at a much higher level than the tympanic membrane, so that in cases where it is desired 16 226 Suppuration of the Middle Ear. to detach the auricle, the superior pole of the line of in- cision will be at a higher level than the annulus tympan- icus. In those cases at an early age where the anterior flap is drawn well forward, the extremely firm attachment of the soft tissues of the meatus above and behind is apt to lead the operator into error in believing that the margin of the annulus has been exposed and if the opening be made in the mastoid under these conditions without the posterior por- tion of the ring being seen and the location of the spina not definitely ascertained, it is perfectly possible that instead of the opening entering the mastoid in the direction of the antrum, it will enter instead into the middle cranial fossa. In order therefore to avoid this very serious error, it is abso- lutely essential that these attachments of the auricle should be thoroughly separated from this portion of the temporal bone until the spina is well defined and it can be seen that the external canal fades away into the membrana tympani, and in order to better' ascertain this latter point, it is always well to make an incision into the fibrous canal so that the tympanic membrane can be clearly seen. Going back to the adult again, the external landmarks do not become altered as a result of sclerosis producing the eburnated type of mastoid. When such a type of mastoid is encountered, the usual opening if allowed to continue for any depth is fairly sure to strike the sinus, or if this is fortu- nately not the case, the further penetration, unless great care can be taken, will result in the opening of the middle cranial fossa. It should therefore invariably be made the rule under these conditions to remove the bone in but thin layers, and after the cortex has been sufficiently opened, to accurately measure the distance inwards at frequent intervals, to use the probe almost constantly, and to hug the posterior wall of the auditory canal as closely as possible; in this way the dangers are reduced to a minimum and the antrum can usually be reached. CHAPTER II. PRELIMINARY PREPARATION OF THE PATIENT FOR OPERATION. 227 PRELIMINARY PREPARATION OF THE PATIENT FOR OPERATION. The preparation of the patient for operation, as regards his general condition does not differ in any essential re- spects from the preparation for operations of like magnitude in any other portion of the body, and it is therefore useless to describe here what is already so well known. However, it is desired to emphasize a few important points in this con- nection and especially that 'it is advisable to have the patient in as good a physical condition at the time of operation as is possible, although in many cases this cannot always be obtained, and the mastoid must be opened with the .patient often septic and ill fitted to stand the necessary operative pro- cedures. As a rule it is advisable to keep the patient in bed the day previous to operation, to restrict the diet and under such conditions it is always advisable to have the bowels thoroughly moved. The well-known injunction to avoid food for a number of hours before operation should also be remembered. As the hair is the most common source from which the superficial skin wound may become infected, it is absolutely essential that the scalp should be shaven in part 229 230 Suppuration of the Middle Ear. or whole as may seem necessary in the particular case. This should be done several hours previous to operation, and pref- erably the day before, while the hair removed should include not only the beard, if the patient be a male, but also an area extending from three to five inches above and behind the auricle. This should be closely shaven in both sexes, while some operators prefer, and it undoubtedly is safest, to shave the entire scalp in males. After shaving the head and pre- liminary to operation, the tissues should be rendered as aseptic as possible in various ways, depending to a great extent upon the choice of the operator. Irrespective of whatever anti- septic solutions may be employed for this purpose, the parts should always be thoroughly scrubbed with soap and hot sterile water, and if not unduly sensitive, a small brush should be employed for this purpose. Not only should the parts that have been shaven be cleansed in this manner, but the entire head, neck and auricle should also be rendered as sur- gically clean as possible, and while many of the liquid soaps prepared for this purpose will be found satisfactory, yet the older tincture of green soap or the ethereal liquid soap are especially efficacious. Following this, the parts should be cleansed of the remains of the soap by washing with a warm, sterile saline solution, and then the areas which have been shaven, or if the hair has been removed from the entire head, the tissues over the temporal bone and adjacent to it should be mopped with turpentine or ether to remove any fatty matter from the skin. Alcohol in the strength of 95 per cent, is then used for cleansing, and following this a I to looo bichloride of mercury solution or a weak solution of carbolic acid is applied in the same manner. Previous to this, or following it, the former, however, being preferable, the external auditory canal should be thoroughly cleansed, and while the tissues in part here are already infected, yet it is essential that the most painstaking antiseptic precautions be Preparation of the Patient for Operation. 231 taken, so that as much as possible of the infective material already present should be removed, and also in order to pre- vent further infection by micro-organisms which may be even more serious than those already present. A syringe should be used for this purpose and the canal washed out with a i to 5000 formaline solution, or a I to 5000 bichloride of mercury solution; in some cases, where the purulent dis- charge is unusually offensive, a stronger solution of bichloride may be employed, such as I to 1000 strength, and then the canal should be thoroughly scrubbed with sterile cotton satu- rated with peroxide of hydrogen. If convenient the cleans- ing of the canal should be performed daily for several days preceding operation, and at the final cleansing, as outlined, the entire canal should be lightly dusted with an antiseptic powder, such as iodoform and the canal occluded with sterile or iodoform gauze. Over the auricle and the entire side of the head, which has been rendered antiseptic, a plain bichlo- ride or carbolic dressing is then applied, and this in turn is kept in place with a bandage until it is removed at the time of operation. If possible the parts should be cleansed as here described the day previous to the operation, but if this is not possible it should be done at least several hours in advance. In cases where there are any purulent changes in the nasal chambers, such as sinusitis, or the patient is suffering from ozoena, these parts should be cleansed with an alkaline, antiseptic solution. It is unnecessary to here give details as to the methods of sterilizing the hands of the operator and his assistants, and the care taken in this respect to avoid infec- tion, as these points are given in every text-book and differ in no way -from such preparation as are made in the perform- ance of general surgical procedures elsewhere. The ques- tion of wearing gloves either of cotton or rubber has not as yet been considered to any great extent in aural operations 232 Suppuration of the Middle Ear. as in general surgery and while in chronic suppurative otitis media the tissues in part at least already contain pus, it would seem that thorough sterilization of the hands by any of the methods commonly in use would be sufficient, but where there is especial danger of entering the cranial cavity or of acci- dentally opening the lateral sinus, one would certainly be more secure in wearing sterile gloves than if such were not the case. At the present time, however, they would appear to be a refinement that are not necessarily of service in all cases. Some mention may be made here as regards the sterilization of the instruments and dressings, all the larger instruments, with the exception of those with a cutting edge, should be boiled in a 2 per cent, soda solution for at least ten or fifteen minutes and then, when ready for use, transferred to pans of sterile water. Knives, of course, cannot be sterilized in this way for fear of damaging them, but they may be placed in the hot soda solution for one or two minutes and then washed with alcohol, or may be rendered perfectly sterile by placing them in formaline vapor for a time, all the dress- ings being rendered sterile, both those which are applied after the preliminary cleansing already described and those used after the operation has been performed. At the time of the operation, after the patient has been anaesthetized, the antiseptic dressings, which have been left undisturbed, are then removed and the tissues again thor- oughly cleansed. At this time the external canal should first receive attention by removing the gauze plug at the meatus and syringing with a saturated boric acid solution or a i to 5000 bichloride of mercury solution, when the meatus is for a time occluded with gauze or not as may be desired. The field of operation, including the neck and auricle are then washed with alcohol or ether and this is followed by a I to looo bichloride solution, with which the parts should again be thoroughly scrubbed. If the entire head has not been Preparation of the Patient for Operation. 233 shaved, the hair should be covered with gauze bandages, either sterile or wrung out in a bichloride solution, while if the patient is a female, an antiseptic starch bandage may be used to keep the hair in place, or if preferred, a sterile rubber cap may be employed for the same purpose. The rest of the head, neck and adjacent regions should then be protected either with dry sterile gauze, or sublimated compresses, or towels wet with the bichloride solution may be employed. CHAPTER III. THE SIMPLE MASTOID OPERATION, 235 THE SIMPLE MASTOID OPERATION. The question of partial or complete failure to cure chronic suppurative otitis media after operation through the external canal, resolves itself into the fact that all the carious and necrosed tissue has not been removed, and this may be readily explained by the pathology of tympanic suppuration whereby in the great majority of chronic cases the antrum and mas- toid cells are involved at a fairly early stage, and cure of necessity becomes impossible until all this diseased tissue is also removed by operative procedure. Both the location of the mastoid process in relation to the tympanic cavity and its histological structure are favorable to this extension of the inflammatory process, and as has been shown by many otologists, the antrum plays the part of a "drip cup," so that when the patient is in a recumbent position, the pus flows backward from the middle ear, it thus becoming impossible to effect a favorable result in such cases without opening the mastoid. In later stages, the pathological changes may even be more marked here than in the tympanum, so that from various causes acute exacerbations taking place, the chronic suppuration for a time assumes all the features of an acute 237 238 Suppuration of the Middle Ear. mastoiditis, or, on the other hand, the symptoms may result from the retention of pus in the mastoid interior. As the cells of the mastoid are lined with the continuation of the tympanic muco-periosteum, it is not difficult to appreciate the sequence of changes, such as the simple inflammation, then necrosis of the mucosa, with a periostitis, osteitis and finally caries. To a great extent, however, the character and area involved, depends upon the anatomical variety of the mas- toid, as for example the pneumatic type is more frequently involved than the diploic, and the vertical portion of the compact process remains uninvolved, even though the process be extensive (see plates XXIV and XXV). In some cases these changes will hardly be in evidence in the portion of the mastoid where such would be expected, but a pus-filled cell in the tip will be the major focus, the rationale of the mas- toid changes in great part being shown by the peculiar placing of the mucous folds or bands in the antrum and its immediate vicinity, which, extending into the adjacent mas- toid cells, do not in the normal condition interfere with the drainage of these, parts, but when it becomes infiltrated as the result of the tympanic suppuration, the drainage becomes inefficient or entirely abolished, and the resultant purulent changes in the mastoid produce the empyema found here. The object, therefore, of the simple mastoid operation, is to effect a communication with the antrum through the mastoid process in order that efficient drainage may be obtained. Before further elaborating this statement, it may be well to state that the simple opening of the mastoid process without entering the antrum, has no place at all in the treat- ment of chronic aural suppuration, and that even the mere opening of the mastoid itself is of little value in this con- dition unless the diseased tissue be removed. It is there- fore implied when using the term "the simple mastoid operation" here, that it is but the basis of the radical The Simple Mastoid Operation. 239 operation, and as will be seen further, is applicable in those cases where the mastoid is not extensively involved and the involved areas may be removed through the opening in the cortex, without throwing open into one large cavity the tympanic cavity, attic, antrum and mastoid, as is done in the so-called radical operation, which is not necessary for the cure of all cases of chronic suppurative otitis. It is impossible for the surgeon to know in advance of opera- tion the amount of tissue destruction present, so it is advis- able to always open the antrum as a primary procedure and then proceed as may be indicated by the conditions present, so that drainage may be effected through the antrum into the tympanum and that healing may take place from within outwards. In order to accomplish this, it should be the object of this operation to break down all the bony lamina separating the cells from the antrum and from the exterior, so that a single cavity is made and the communication be- tween the antrum and tympanum, which is usually narrowed by granulation tissue, is freely opened for drainage. This is the so-called Schwartze operation in distinction to the radical operation which goes by a number of titles, depend- ing upon its modification, and which comprises the exen- teration of both the tympanum and mastoid. While a few radical otologists state that the Schwartze operation is indi- cated only in acute mastoid abscess and is not adapted for the surgical treatment of the condition under consideration, yet this, in the opinion of the writer, is not the case, as this oper- ation will in a number of cases be followed by successful results and further it forms the basis of all mastoid opera- tions in which the opening is made through the cortex in con- tradistinction to Stacke's operation. Schwartze's method representing an operative procedure, which may be modified to fulfill the requirements indicated, up to the complete rad- ical operation. 240 Suppuration of the Middle Ear. Probably the most difficult problem in chronic suppura- tive otitis media at the present time is to know when to open the mastoid in the absence of any well-marked symptoms pointing to its involvement, and while general indications may be formulated, the question as regards the individual case must be solved by the particular conditions present in that case. In general, irrespective of the operation to be performed upon the mastoid process, the indications for operation, as laid down by Politzer, are of great value and it is desired to indicate some of them here, both as a basis for indicating when, as far as possible, the simple Schwartze operation should be performed, and as being of value in making clear the reasons for the various operative pro- cedures to be further described. He divides these indica- tions for operation into two classes, subjective and objective. The subjective are the persistence of pain in the ear or over the mastoid process ; permanent or intermittent attacks of vertigo due to erosion of the external semicircular canal ; and marked cerebral disturbance. The objective symptoms are: (i) Caries of the wall of the tympanum. (2) Gran- ulations and polypi in the vicinity of the aditus and recur- ring quickly after removal. (3) Fistulous openings in the cortex. (4) Cholesteatoma. (5) Hyperostotic stricture of the external auditory canal. (6) Facial paralysis or paresis. (7) Painful swelling of the mastoid. (8) Prolonged fcetid suppuration resisting treatment, especially if the upper pos- terior region of the membrani tympani is perforated and its remnants are adherent to the internal wall of the drum cavity, and more so if pus and epithelial masses can be drawn from the region of the aditus by aspiration. (9) Symptoms of tuberculosis occurring in a case of chronic suppuration (aural suppuration in a case with pulmonary tuberculosis being a contraindication for operation on the mastoid). (10) Evidences of intracranial or sinus involve- The Simple Mastoid Operation. 241 ment. He further believes that when the objective signs are accompanied by some of the more serious subjective signs, operation becomes imperative. But the clinical symptoms do not, however, always correspond to the pathological find- ings, as we may find a small amount of granulation tissue or pus in the antrum with alarming symptoms, or grave path- ological changes, with but few symptoms. So that this makes it impossible to lay down strict rules of the indications for operation, although he believes that the mastoid opera- tion is not justifiable in ordinary chronic suppurative cases, until it has been proven that conservative treatment will not cure. Many of these indications will most strongly militate against the simple mastoid opening as being insufficient to be of any value, the class of cases in which this oper- ation is specially indicated being those in which the symp- toms, both subjective and objective, indicate the limitation of the morbid process to the antrum and its immediate neigh- borhood towards the mastoid cortex, and in which serious symptoms, such as facial paralysis, vertigo, intracranial in- volvement or sinus changes, are not present. From a purely pathological aspect, one should choose the radical operation if the symptoms show the temporal bone to be extensively involved, and especially if cholesteatoma be present, as under no circumstances should the simple operation be performed when the latter condition is found to exist. Milligan states that when the suppuration has persisted for twelve months, with careful local treatment for three months with no avail, the mastoid antrum and contiguous cells should be opened and cleaned out, the form of operation, whether Schwartze, Stacke, or a modification, depending on the peculiarity of each case. Luc gives the indications for opening the mas- toid when it is desired to give vent to pus in retention; to circumvent conditions indicating threatening or the com- 17 242 Suppuration of the Middle Ear. mencement of intracranial infection, and for the cure of the aural suppuration after operation by way of the meatus has failed. Schwartze believes these indications to be : ( i ) Re- current inflammation of the mastoid which constantly reap- pears, this indication being strengthened when there is a fistula or the burrowing of pus. (2) When the exterior of the mastoid is healthy, but there is evidence of inflammatory retention in the middle ear. (3) As a prophylactic opera- tion to facilitate drainage in incurable foetid suppuration, even with no evidence of retention. While Macewan states that, as a general rule, when pyogenic lesions exist in the middle ear or its adnexa, which are either not accessible or cannot be eradicated through the canal, the mastoid cells and antrum should be opened, these cases being divided into two classes: those in which the patient's life is, or is believed to be, in immediate danger, and a second class in which the principal object is to remove the cause of the suppuration, to improve the present condition, and to relieve the patient from the danger of future complications. The operation under particular consideration is indi- cated in that class of cases in which the pus in the pneumatic cells in the location previously pointed out is represented by a localized empyema, but not in those cases where there is marked suppuration of a diploic mastoid or serious inflam- mation of the cortical substance. In other words, it is indi- cated where the hearing on the affected side is fairly well preserved, and where the tympanic suppuration has resisted local treatment and intratympanic operation, but in which mastoid symptoms are not in evidence. The involvement of the mastoid from the suppurative process in the tympanic cav- ity is practically an essential part of the pyogenic process, but it is also influenced and enhanced by various factors which prevent the free discharge of pus from the tympanic cavity, and thus aid in its retention, with consequent stagnation and The Simple Mastoid Operation. 243 decomposition. Especially is this evident when these changes take place in the mastoid process, so that caries and necrosis ultimately results with absorption or destruction of the bone substance, the most prominent factors concerned in these changes being a narrowing or stenosis of the external audi- tory canal and the more or less complete obliteration of the tympanic cavity by granulation tissue, polypi or cholesteato- matous masses, these conditions often being evinced when the membrana tympani is not destroyed by a perforation at the margin of its postero-superior quadrant and suppura- tion in the epitympanic space with a perforation in Shrap- nell's membrane. While general anaesthesia is practically always necessary in the performance of mastoid operations, yet Alexander has reported several cases where for various reasons this was inadvisable and Schleich's local anaesthesia was used. In some of the cases the operation was quite extensive, and in order to diminish the shock and the sound of the hammer used in striking the chisel, the head of the same was cov- ered with muslin. While the local anaesthesia was not abso- lute, it was sufficient to ensure comfort, and there were no dangerous symptoms or unpleasant sequelae, although in some of the cases the operation lasted longer than an hour. The solution that was used for this purpose consisted of one grain of cocaine to the ounce of distilled water. While in extremely rare cases local anaesthesia may be employed, yet at the present time one would hesitate to relieve the pain of the operation in this very uncertain manner, and it may be laid down as a rule that general anaesthesia should be employed in all cases where the mastoid operation is per- formed, either in the simple opening of the antrum or in any of the so-called radical procedures. After the patient has been anaesthetized, the original dressings removed and the field of operation again rendered 244 Suppuration of the Middle Ear. sterile, the first step in this operation is the primary incision (see plate XXVI) over the mastoid process. Both the loca- tion and extent of the incision varies considerably with the particular practice of the operator and the extent of the dis- eased process if evidences of such be present upon the skin of the mastoid. As a rule it is advisable to begin the incision well up at a point nearly corresponding to the top of the auri- cle or slightly above the meatus ; this cut should be somewhat curved in outline and at first it should be carried slightly backwards in a semi-horizontal direction, and then extend- ing vertically, it should extend as far down as the tip of the mastoid process. Again, in other cases, the post-auricular incision may be made parallel to the auricle, and commencing above, at, or about the centre of the mastoid, may extend to slightly above its base, and if the space obtained by this incision is not found to be sufficient, then a second small incision may be made, extending backwards from the highest point of the original incision. As far as possible it is advis- able to make the incision close to the auricle or in the pos- terior auricular groove, so that the resultant scar will be hidden by the pinna, but it should be at a sufficient distance to admit of sutures, if such are to be applied. Usually from one- fourth to one-half inch will allow readily of this, and it should also be placed at such a distance from the auricle that the field of operation will be well exposed, yet the cicatrix will be hidden as much as possible, and the auricle to retain its normal position. Under no circumstances, however, should the operative field be lessened for any of these reasons, an incision which begins immediately below the temporal line, about one-half inch behind the insertion of the auricle, and being placed at first vertical, then slightly curved forward, and then extended downward to near the tip of the mastoid, will usually be most satisfactory. Some otologists prefer to reverse this procedure and begin the incision over the EXPLANATORY NOTE TO PLATE XXVI. This plate shows the primary retro-auricular incision in the performance of the mastoid operation. This incision should be carried through the periosteum to the mastoid cortex. 246 PLATE XXVI The Simple Mastoid Operation. 247 middle of the mastoid insertion of the sterno-mastoid muscle, about a fourth or half an inch below the tip of the process, and from this point it is carried upwards and forwards, close to the line of the insertion of the auricle, where it follows this line to a point directly above the external orifice of the auditory canal. Should the skin over the mastoid be in- flamed or infiltrated to any extent, the incision may have to be made still larger, and it may be even necessary to make another at right angles to it to sufficiently expose the parts. In practically all cases, with the exception of a very small number where at the upper end the incision may be made only through the skin, it is essential that it be made down to the bone, the first incision severing any muscular tissue that may be present in its upper part with the fascia and the periosteum, so that the soft parts are divided throughout their whole extent. The periosteum is then pushed forwards and backwards with the periosteal elevator, so that the planum mastoideum is freely exposed and the bleeding controlled. Should the incision in its lower part have been well forward, the pos- terior auricular artery will be severed and this vessel, with any others that may be bleeding freely, should be clamped. As a rule, after the periosteal flaps have been pushed aside by carefully dissecting this membrane up from the osseous surface, avoiding tearing it as much as possible, the oozing usually ceases from the pressure exerted upon the flaps by the retractors, but if it still persists, it is generally controlled by firm pressure with gauze sponges wrung out in hot water and retained over the parts for a few moments, one of these being left in the upper part of the incision for this purpose, if such be necessary. In those cases where the soft tissues are congested and where the oozing is excessive and yet of such an extent that hsemostatics are of no use, it will be necessary to delay further procedures for a few moments 248 Suppuration of the Middle Ear. and pack the entire incision with small sponges as described, while in those cases where in separating the posterior perios- teal flap the mastoid emissary vein has been divided, it may be necessary to pack the tissues with a small piece of gauze and allow it to remain in place until a later stage of the operation. While some bleeding from this vessel is not at all infrequent, it is comparatively rare that it is of any moment, but in these cases especially, if there be much con- gestion about the head, it is apt to produce a free venous hemorrhage and for a time cause the operator considerable annoyance. Very often the free vascular supply of the anterior flap causes it to become more or less rapidly cedematous, but this is of little moment and requires no special attention. The flaps should be retracted so that the cortex is well ex- posed and the anterior flap especially should be drawn suffi- ciently forward, so that the supero-posterior margins of the bony canal can be seen in order that the landmarks for guidance to the antrum can be accurately located (see plate XXVII). Various retractors may be used for this purpose, but in cases where there is apt to be much pus present, it is advisable to use those where the teeth are not too sharp, as they are apt to lacerate the tissues of the flap and materially increase the likelihood of causing some annoyance from sub- sequent local infection. The exposed surface of the cortex is then carefully ex- amined. In the great majority of these cases it will appear to be perfectly normal, or there may be a fistula present, or in a few cases a portion of the surface will appear dark in color, or mottled here and there with small bleeding points, the former condition indicating a beginning necrosis, while the latter suggesting a marked congestion or engorge- ment of the venous system of the mastoid interior. Should bare bone, a fistula or any other lesion of the cortex be EXPLANATORY NOTE TO PLATE XXVII. This plate shows the primary incision carried through the skin and periosteum, with the soft parts retracted, exposing the underlying bone and the field of operation. A portion of the external cartilaginous auditory canal is also exposed. i, Retracted skin; 2, retracted periosteum; 3, linea temporalis ; 4, external audi- tory canal ; 5, supra-meatal spine ; 6, point of election in entering the antrum (shaded portion). 250 PLATE XXVII The Simple Mastoid Operation. 251 present, it is always advisable to ignore it for a time, unless it be directly over the site of the antrum, and after locating the situation where it is desired to chisel away the cortex by careful search for the landmarks previously described, the antrum is entered as the objective point, when attention then can safely be paid to the lesions of the cortex. The land- marks used as guides to determine the location at which the opening in the cortex may be made in order to reach the antrum by the shortest and safest route have already been described in the previous chapter, but it must be borne in mind that after the cortex has been exposed in order to uncover the site of election, it is necessary that the pinna should be drawn well forward, so that the osseous entrance to the meatus can be seen, as the auricle in its natural posi- tion covers these parts and is placed somewhat over the anterior part of the mastoid process. Bearing in mind the location of the antrum, that is just below the superior and behind the posterior margin of the osseous canal, the open- ing in the cortex previous to the opening of the antrum should not be extended above the superior wall of the canal in order to avoid entering the middle cranial fossa, and at the same time one should avoid extending the opening pos- teriorly, for fear of encountering the lateral sinus. As the postero-superior wall of the meatus is the most important landmark for this purpose, the cortex should never be touched until this part can be seen, and when it is thus located, the antrum can always be reached by chiseling inward and for- wards, parallel to this portion of the meatus, and as the excavation is continued in this direction, one should use the probe at frequent intervals to determine the nearness of the antrum, or the possible exposure of the meninges or lateral sinus. Various mechanical devices have been employed for the purpose of locating the antrum, the mastoid hook guide of Buck being quite serviceable for this purpose. As em- 252 Suppuration of the Middle Ear. ployed by its author, the curved end is introduced from above into the orifice of the external auditory canal and held by an assistant between the bone and the overlying soft parts until the antrum has been reached, when it should be re- moved. When it is hooked into the canal, the hook indi- cates the position of the posterior upper curve of the orifice of the auditory meatus, and the position of the antrum is a scant quarter of an inch behind and a little above that of the steel knob. Buck further states that the operator may then satisfy himself that he has reached the antrum by his knowl- edge of the anatomy of this region telling him whether the cavity which has been reached fulfils in a general way the anatomical requirements or not. If its distance from the surface of the bone by actual measurements is less than one half inch, it would simply indicate an outlying cell. By introducing a probe bent at nearly a right angle with its shaft, in case of the antrum being opened it will slip forward into the posterior end of the tympanum, while if it be but an outlying pneumatic cell, the probe would encounter only a rigid wall. This may also be ascertained, he states, by forcing fluid or air under moderate pressure in the tympanic cavity by way of the external canal, and it will then come out through the antrum, but any pressure in the reverse direc- tion should not be used. If a depth of three-quarters of an inch has been reached without finding the antrum, one should not go to any further depth, as the chances are the opening is either too low down, too high, or too far back- wards, and under such circumstances, if the operator is in the right direction and he is sure the antrum is not present, then he may work cautiously forward until the tympanum is reached. The situation of the opening in the cortex of the mastoid should, as far as possible, be placed just behind the external meatus and immediately below its superior border ; this cor- The Simple Mastoid Operation. 253 responds to the anterior superior quadrant of the mastoid and is the position from which the antrum will be reached in the shortest time. It should lie behind the linea tem- poralis at the height of the superior wall of the external auditory canal, and from 5 to 7 millimeters behind the supra- meatal spine. By following this plan and thus opening the antrum as the initial point, one is able to obtain definite information as to the condition of the mastoid interior, and little difficulty will be found in working intelligently and safely in the other portions of the osseous tissue, where it may be necessary to remove diseased bone, while, if one attempts to find the antrum by first entering any sinus which may appear on the cortex, one is more apt to go astray. In those cases where it is desired to perform this operation, when the mastoid is eburnated, the opening in the cortex should always be in a direction forward and upward towards the aditus, very much like Stacke's operation, in order to avoid the lateral sinus which is very apt to be placed decidedly forwards in this type of temporal bone. It must also be remembered in all cases, whatever the type of bone found, that the highest point of the opening in the cortex should not be placed higher than the upper wall of the osseous canal, and while it may not always be possible to exactly define this limit, one may say as a general rule that it corresponds to the depression that lies below the spina; this depression, as previously mentioned, being directly over the antrum and in a few cases may resemble a well-defined pit. When the spina suprameatus is not present and cannot be utilized as a landmark, one must guide the position of the opening in the cortex by that part of the planum mastoideum which enters into the posterior wall of the auditory canal. This landmark is used as the anterior limit of the opening, and its superior boundary is measured by the upper wall of the osseous external canal; to locate these osseous boundaries it 254 Suppuration of the Middle Ear. is necessary that the auricle be pushed far forward with the periosteal elevator, so that the postero-superior circumfer- ence of the canal can be both seen and felt. In order to remove the cortex over the area selected, the chisel and mallet may be employed or a small aperture may be drilled in the bone with a gouge or drill, the opening being enlarged and the mastoid cells between the cortex and the antrum being broken down with the chisel, curette and rongeur forceps. When the hand gouge is employed for this purpose, it takes a longer time to remove the bone than when the mallet and chisel are used, and it is attended with a greater degree of safety, as it can be easily controlled, even when the hardest bone is being cut through, although, in careful hands, it offers no marked advantages over the em- ployment of the other instruments for this purpose. Blake, in order to make the aperture in the cortex, uses a long broad- bladed drill, cutting at an obtuse angle, and which is rotated with one hand while it is held firmly in place with the other ; the small opening thus made in the bone being enlarged to the size desired with the chisel. Irrespective of the nature of the instrument employed in opening the cortex, as soon as it is made of sufficient size, the opening is enlarged with the rongeur forceps, and as in the majority of cases it is impossible to introduce these forceps until the edges have been undermined to some extent, it is necessary to use the various forms of sharp spoons or curettes, especially Volk- mann's, which are admirably adapted for this purpose, to remove the framework of the pneumatic or diploic tissue, in order to excavate the softened bone. In a general way both the drill and the trephine are not as safe as the chisel, as when the latter is intelligently employed in re- moving the firm cortex, it is almost impossible to do any harm. Both large and small straight chisels are em- ployed for this purpose, and while they are obtained under EXPLANATORY NOTE TO PLATE XXVIII. This plate shows the external cortex of the mastoid removed and the mastoid antrum opened. i, Mastoid antrum; 2, probe introduced into the mastoid antrum; 3, the remains of the posterior osseous wall of the external auditory canal ; 4, the mastoid cells removed down to the inner table of the skull. 256 PLATE XXVIII The Simple Mastoid Operation. 257 various names, those of Schwartze are especially valuable, as they are both strong and narrow, the latter feature ren- dering them more useful than a broad chisel for the ma- jority of cases. As near as possible, the chisel should be held tangential to the skull and but small chips of bone should be cut away with each blow of the mallet, a lead-filled or compressed rawhide mallet being best for this purpose. In cutting away the hard bony layer the chisel may be held with its bevel edge towards the inside of the opening, or it may be held in a reverse position, as may seem best, the posi- tion of the instrument in this respect being dependent upon the fancy of the operator. For the first cutting away of the opening into the bone, the chisel should be rather large, but as the cavity becomes smaller inward a narrower one should be employed and held more at an angle to the bone than the large chisel. When the mastoid is large and rounded and the chisel is applied nearly parallel to the sur- face of the bone, fairly large, thin, broad chips may be cut away from the superficial layers of the cortex, the cutting edge being directed forward and downward, so that when the antrum has been entered the cavity forms a funnel-shaped entrance, with its large base represented by the opening in the cortex and its apex lying in the post-meatal triangle which directly points inwards to the antrum (see plate XXVIII). When the mastoid process is very hard and compact in struc- ture and the curette or gouge are unable to make but little impression upon it, the chisel is necessary to remove the layer of bone external to the antrum, but as in these cases the latter cavity is apt to be small, one should proceed very cautiously, and constantly bear in mind the exact direction in which it is desired the canal should be made, as in using the chisel for this purpose, if one does not pay strict attention to this essen- tial point, the chisel may be directed too far upward, and the cranial fossa may be entered above the roof of the antrum, 18 258 Suppuration of the Middle Ear. or again, if it be directed too far inferiorly, the extremely compact mass of osseous tissue containing the facial nerve near the aditus will be encountered, but this latter accident can only occur in very exceptional cases. The size of the opening in the cortex should, as a general rule, be as large as possible, so that any increase in the intra- tympanic pressure may be relieved, and in order that soft- ened bone and granulation tissue can be thoroughly removed. Where the tissue changes are but limited in extent, and the main object of the operation is to obtain free drainage through the tympanum and antrum, a space of about one centimeter square immediately behind the upper part of the meatus and on a level with the supramastoid ridge, will usually suffice at least for the initial opening, as it can then be enlarged to suit the exigencies of the case, if the condi- tion of the mastoid interior demands it. When the pneu- matic cells have been exposed and granulation tissue or pus is found, the opening in the bone should be enlarged to a size sufficient to remove all the diseased tissue, so that if it be made of sufficient size, one is enabled with good illu- mination to see exactly what is being done, and diseased tissue in the interior may be safely removed, even in the region of the antrum and aditus, without any danger of damaging the facial or horizontal semicircular canals. Schwartze states that the size of the opening in the cortex should be about twelve millimeters, while Bezold thinks seven millimeters is sufficient, but the larger the opening, compat- ible with safety, the better will be the ultimate results of the operation, as with a large opening one can see better, the antrum is more readily found, and what is also important, if the opening in the bone be made too small, the wound is very apt to close before the cavity heals from the bottom and pus retention is fairly sure to take place, necessitating its reopening. The Simple Mastoid Operation. 259 While the pathological changes found in the mastoid interior vary in almost every case, at least in detail, it seems to be a fixed law, as shown by Politzer, that with chronic suppurative processes near the antrum a subacute condensing osteitis takes place which involves all the pneu- matic spaces which escape injury during the original acute attack. This is characterized by the formation of new bone tissue, until solid ivory-like bone replaces the air cells and sclerosis or hyperostosis of the cortex is a regular charac- teristic of chronic suppurative otitis media. As has also been shown as having an important bearing on the symp- toms such a bony wall on the outer side offers an impassable barrier to the escape of pus, and so the characteristic symp- toms seen in acute mastoiditis are absent of necessity. In some cases the degree of the chronic proliferative osteitis will be found so marked that in addition to the usual oblitera- tion of the cells, the small venous channels are also entirely effaced and the entire mastoid process is converted into dense, eburnated bone, so that the antrum is considerably reduced in size and its location becomes a matter of consid- erable difficulty. This only occurs, however, when the chronic suppuration has existed over many years, and when this condition occurs in individuals at or past middle life, and even a slight discharge is present from the middle ear, they should be strongly urged to have an operation per- formed on account of the extreme thickness of the cortex markedly increasing the tendency towards the deeper exten- sion of the purulent process, be it soever limited in extent. When this condition is surmised, however, in advance of operation, it is futile to expect favorable results from the mere opening of the mastoid, and in order to cure the sup- puration the posterior wall of the auditory canal must be removed to reach the antrum, so that a Stacke or Zaufal operation is usually indicated; the former if the condition 260 Suppuration of the Middle Ear. be recognized previous to opening the cortex, and if not, the simple operation should be so modified and enlarged as to suit the particular case. In a second large group of cases, the conditions present in the mastoid interior, after the cortex has in part been removed, are directly opposite to those just described, and instead of the development of new tissue, we find a breaking down of the walls of the pneumatic spaces, with limited caries and necrosis. Briefly noted, these changes may be found side by side in one case, or one or more may pre- dominate and necessitate the performance of a radical oper- ation instead of the more simple one. As shown by Politzer, there may be hypertrophy of the mucous membrane of the antrum and mastoid cells, due to proliferation of round cells, so that the mastoid spaces become filled up and obliterated by the proliferating mucosa. This tissue may persist, how- ever, or it may become transformed into bone, causing par- tial or complete eburnation of the mastoid, or again, we may find a granular osteitis and carious softening of the walls of the antrum, which becomes abnormally widened, rarely narrowed, or complete destruction of the antrum with ex- tensive sclerosis of the mastoid process. In other cases there may be a circumscribed or diffuse caries or necrosis of the mastoid, with or without the formation of a sequestrum. Cholesteatoma of the antrum or mastoid cells may also be present with the presence of pus and thickened caseous masses similar to tubercular material, while, as a rule, in all cases of long standing, hyperostoses and osteo-sclerosis of the bone takes place, surrounding the seat of the disease. At one place in the bone the various infecting organisms present may produce but sufficient irritation to cause the development of a group of granulation tissue, while in an adjacent area the epithelial cells will appear to have borne the brunt of the inflammatory changes and excessive prolif- The Simple Mastoid Operation. 261 eration will have taken place, forming irregular groups of cells or a well-defined laminated cholesteatomatous mass, with thick curdy pus and considerable destruction of the osseous wall surrounding it, so that when this condition is revealed, it is necessary to eviscerate the entire affected mas- toid and tympanic contents and preferably maintain a perma- nent retro-auricular opening, as will later be described. In the larger number of cases operated upon for the cure of the chronic tympanic suppuration, granulation tissue, more or less epithelial debris and carious areas will be found after the antrum has been opened, while the vertical part of the mastoid will be found less frequently involved, irrespective of the nature of the mastoid structure. Unless the patho- logical changes of the osseous structure itself are well marked, it is often difficult to determine by inspection, and even from the degree of firmness of the bone, whether it is sufficiently healthy to be allowed to remain or should be removed. If it is very vascular, of a dark red color and when cut bleeds persistently, or there is the reverse of this, that is, a complete stasis of the vascular channels, it is prob- ably involved to such an extent that it will be impossible for it to again return to the normal condition, and it should be removed until absolutely healthy bone is reached. If the field of operation be made sufficiently large, it is usually pos- sible to recognize and remove the grosser evidences of the diseased osseous tissue, these areas, if not actually broken down, often being clearly distinguished by masses of granu- lations in the cell spaces, and when this occurs, one will always be safe in removing such areas in toto, with the bone in their immediate vicinity. In many of these cases it is of course impossible to tell until the interior of the mastoid has been reached whether a condensing osteitis or an empyema with more or less exten- sive necrosis is present, and very often the subjective or 262 Suppuration of the Middle Ear. objective symptoms do not agree in any way with the patho- logical changes which are found on operation, as one may have more or less serious symptoms and yet there will be but a small amount of granulation tissue present. While in other cases all symptoms except a slight discharge from the canal will 'be absent and when the cortex of the mastoid has been removed, extensive and serious disorganization of the temporal bone may be disclosed, the uncertainty of the nature of the pathological changes being recognized previous to opening the bone, and is well expressed by Schwartze when he states that often the diagnosis of empyema of the mastoid is made only after operation. The bony structure, whether consisting of large cells or diploic tissue beneath the cortex, should be removed with the curette or sharp spoon, and this must be continued until the antrum is reached. The extent of the removal of the cells depends entirely upon the amount of the disease present, and that which may be regarded as the simple opening of the antrum in some cases will ulti- mately, as the result of finding extensive disease present, be finally terminated in a complete evisceration of the parts. Should it be found that the tip of the mastoid is filled with pus, the opening in the cortex should be sufficiently enlarged to enable one to remove this cellular group, and if the dis- ease appears to be extensive in this locality, one should care- fully dissect up the bony insertion of the sterno-mastoid mus- cle with curved scissors and examine the osseous tissue re- maining for a carious process of the medial plate leading into the digastric fossa. As we may now consider that the antrum has been opened, one should then proceed to lay bare all accessory cells that may be diseased, so that the cavity remains per- fectly clean and no pockets are left that may continue the aural suppuration. Even should a sinsrle isolated cell be left containing pus, the symptoms, although relieved for a time, The Simple Mastoid Operation. 263 will generally persist, and it will later become necessary to perform a secondary operation. In many of these cases, after exposing the antrum and excavating downwards with the curette towards the tip, one is very apt to find one or two large pneumatic cells here and after these have been destroyed, it is well to explore in a backward direction towards the temporo- occipital junction and then again using the antrum as an objec- tive point, the bone may be explored upwards and backwards towards the inner osseous plate. Should the inner table be involved in the carious process, it is essential that it be re- moved, and although both dura and lateral sinus will thus be exposed, yet in such instances if proper antiseptic precau- tions have been employed, one can be fairly confident that this will not seriously complicate the operation. Irrespective of the structure of the mastoid, that is, whether it is can- cellated or not, and this latter variety may sometimes extend far backwards and even far inwards, it should be remem- bered that it is absolutely essential to widely open all pus cavities or spaces in which pus may lodge. The antrum and the passage between it and the tympanic cavity should also be curetted with a small sharp spoon, as in many cases where this method of opening the mastoid is employed, the major part of the disease will be found located here, and the ces- sation of the tympanic purulency will to a great extent de- pend upon the removal of the granulation tissue and pos- sibly the carious bone areas from the region of the aditus. While, as before mentioned, it may be sometimes quite diffi- cult to differentiate normal from diseased bone, yet as a rule the latter is easily broken down with the sharp spoon, and if one finds that in the particular case this is the condition met with, it should always be scraped away until healthy osseous tissue is reached, and this is usually recognized by a certain peculiar resistance which it offers to the cutting instrument. The extent of the removal of the mastoid con- 264 Suppuration of the Middle Ear. tents, will as a fact, depend upon meeting the healthy bone surrounding the involved parts, and as one of the aims of this procedure is to destroy as little of the parts as possible, although this is but a secondary and minor consideration, it is not advisable to extend the operation beyond the affected area unless there are well-defined reasons for so doing, and as has been stated by several authors, this should be the guiding rule as to how extensive an operation should be performed in such cases, McBride in this connection not considering it always necessary to clear out the mastoid in such cases of chronic otorrhoea. After the diseased tissue has been removed as indicated, the walls of the cavity which has been made irrespective of its size, should in all points be composed of firm, healthy bone, and after this has been ascer- tained, the edges of the external opening of the cavity should be smoothed down with the rongeur forceps and any over- hanging border which still remains must also be removed in the same way, so that no irregular edges will be left to cause trouble with the later dressing of the wounds. Previous to the curetting of the mastoid cells, one should always be sure that the antrum has been opened. Should the mastoid not contain marked pneumatic tissue, it is not advisable to penetrate to a greater depth than three-quarters of an inch for fear of wounding the facial canal or the labyrinth, for as a rule, the antrum is rarely less than one- half an inch from the cortex, and it may be verified by pass- ing a moderately curved probe through it in a downward, forward and inward direction, so that if the space be the an- trum, the probe will be felt in the tympanic cavity as it passes through the aditus, instead of meeting the obstruction of os- seous walls should the cavity be but a large pneumatic space lying between the antrum and the exterior of the mastoid (see plate XXVIII). It is impossible in searching for the antrum to know the depth of the canal which is being excavated and EXPLANATORY NOTE TO PLATE XXIX. This plate shows the completed simple mastoid operation (Schwartze) on a bone specimen. i, zygomatic process; 2, external auditory canal; 3, posterior osseous canal wall; 4, stylo-mastoid process ; 5, an opened terminal (tip) cell of the mastoid process ; 6, bony prominence over the sigmoid sinus ; 7, digastric fossa ; 8, mastoid antrum. 266 PLATE XXIX The Simple Mastoid Operation. 267 which various authorities quote different distances from the cortex to the external wall of the antrum, and yet the differ- ent figures can be fairly well harmonized if one considers that the point from which the measurements are made on the cortex varies in the different methods recommended for opening the mastoid. This is shown by Politzer, who states that Schwartze gives the distance from the posterior edge of the opening in the bone to the antrum as about twelve to eighteen millimeters, while Bezold, measuring from the an- terior edge of the bony opening, makes it but twelve milli- meters. As the distance of the spina from the supero- posterior periphery of the membrana tympani averages about fifteen millimeters, an important guide is thus furnished how far we may advance when chiseling away the osseous tissue. The distance between the middle of the external opening in the bone and the external wall of the antrum varies from six to fifteen millimeters, and as the horizontal semicircular canal or facial nerve is reached at a depth of from twenty to twenty-two millimeters, one should not go deeper than eighteen millimeters if the antrum is not found. In children, as has already been shown, the antrum lies much nearer the surface, and in many cases of chronic sup- purative otitis in this class of patients, the simple opening of the mastoid will be all that is indicated, the procedure being carried out essentially as in adults as regards the oper- ative technique, but in very young children with due regard to the varied topography of the temporal bone. Meniere, in a comprehensive study of the mastoid changes in chil- dren as influencing the operative treatment of chronic sup- purative otitis media, found that the condition is quite fre- quent, being present in three hundred and fifty-six of one thousand seven hundred and forty-eight cases. He also states that as the mastoid is formed during the first year of life by the slow absorption of cancellous bone, the often slow, 268 Suppuration of the Middle Ear. painless and insidious course of affections of the mastoid cells may be readily explained and the extension of the mas- toid caries from the interior to the exterior without pain or symptoms is frequently observed in predisposed young sub- jects where the aural suppuration has not been properly treated. Notwithstanding the benignity of this consequent mastoiditis in many young children, if proper local antiseptic treatment does not cure the affection, one should first remove the carious ossicles, and if this is not sufficient, then open the mastoid and if necessary continue with the exposure of the middle ear, such radical procedures being necessary because experience has shown that the mastoid infection occurs insidiously and slowly and often does not give any early diagnostic symptoms. The dangers of curetting are reduced to a minimum if care is used in dangerous areas, and if the amount of force used be not in excess of that necessary to remove the diseased tissue. In the antrum, when the sharp spoon is employed, care of course must be observed on account of the important structures, and in curetting well into the aditus one should, as in the operations through the intact meatus, cut away from the facial canal and the stapedial region, rather than in a direction towards them, while in all parts of the mastoid process precautions must be taken against undue force, ex- cept when one is in the direct line of the antrum, when con- siderable force may be employed here as long as one keeps in a direction forward and below the upper wall of the ex- ternal canal. The danger of accidentally opening the lateral sinus is not at all a theoretical one in these cases of chronic suppuration, as the mastoid structure is often sclerosed and exceedingly hard and at the same time the sinus is in closer relation to the auditory canal than in the perfectly normal mastoid. As the curette or spoon is of little or no value under these circumstances, the chisel must be employed and The Simple Mastoid Operation. 269 every step of the operation carefully watched for the sinus wall, as in some cases it is perfectly possible that this vas- cular channel may be placed so far forwards that there is little space for the particular operative field. As a guiding rule to avoid the possibility of opening the sinus, one should at first excavate the bone in a limited area inwards, forwards and slightly downwards and keep as close as possible to the canal wall, enlarging the upper part of the excavation as one works inwards. Chincini reports four cases of invol- untary opening of the sinus during operation, but the hemor- rhage was controlled by plugging with gauze and all the patients recovered without any complicating condition. Should the antrum be entered without interfering with the sinus, the posterior wall of the funnel-shaped cavity should be carefully chiseled away if necessitated by pathological changes present, as this is the portion in relation to the sinus, but in the vast majority of cases if the chisel be held cor- rectly, that is, the cutting edge in a direction forming an acute angle with the vessel, there will be practically no dan- ger, as if the sharp edge of the chisel should press against the elastic wall of the vessel the instrument will usually push it aside without doing any damage unless its walls are dis- eased, when profuse dark venous hemorrhage immediately occurs. Sometimes in removing the bone in the region of the sinus a profuse hemorrhage may take place that for an instant simulates very closely the profuse bleeding from an open sinus, but by firm pressure with gauze for a few mo- ments this will cease and it will then be seen that it comes from the mastoid emissary vein which has been severed near the point where it empties into the sinus. Should the re- moval of an area of bone expose the sinus wall, it may be readily recognized by its position, that is, internal or pos- terior to the cavity which is being excavated, and also by its bluish-gray coloring, while the probe will show that it can 270 Suppuration of the Middle Ear. be indented by light pressure. Should the sinus be acci- dentally perforated when the cortex has been extensively re- moved and the bone cavity is of fairly large size, the hem- orrhage may be controlled by packing over the bleeding area with iodoform gauze and retaining it in place for about twenty-four hours, while the operative procedures in other portions of the bone cavity may usually be continued, but when the opening in the cortex is small, it may be necessary to entirely fill it with the gauze to control the bleeding, and under these circumstances it will be impossible to continue the operation until the sinus wall has healed. As the roof of the antrum forms in part the middle cere- bral fossa, its position externally is figured by the linea tem- poralis, the floor of the fossa practically never being over a centimeter below this line, so in the vast majority of cases one can avoid wounding the dura when endeavoring to enter the antrum or removing the necrosed tissue from this par- ticular region by keeping about a centimeter below the tem- poral line when this can be used as a landmark, while in those exceptional cases where it can not be plainly made out, the upper edge of this portion in the opening in the bone should be from two to three millimeters below a line drawn hori- zontally backwards from the postero-superior edge of the external meatus. If minute attention be paid to the anti- septic features of this operation, such accidental exposure of the sinus and dura will not be of very serious importance, as the small area of bone exposing them will reform within a reasonable time if it be anyway healthy. Sometimes if the dura be exposed, it may be subjected to a certain degree of traumatism by small sharp-pointed splinters of bone during the removal of necrosed osseous tissue in its vicinity, but if care be taken to use the curette under such circum- stances, this is not liable to happen, and if of necessity the chisel be employed, this danger to the meninges may be The Simple Mastoid Operation. 271 almost always avoided by chiseling away the osseous tissue in a direction parallel to the roof of the antrum. Before describing the finishing steps of this operation, brief atten- tion must be directed to the danger of extensive destruction of bone which may sometimes follow the infection of opening lip the diploic tissue, while these cases are quite unusual, yet they are being reported more and more in the literature and resemble closely a well-defined osteomyelitic process. While this extension of osseous infection may be dependent upon numerous factors, some recognizable and others ob- scure, yet much may be done towards its prevention by rigid attention to aseptic precautions previous, during and following operation until the aural suppuration has entirely ceased, and if every portion of the osseous tissue exposed is surgically cleansed and all foci for further retention of pathogenic organisms removed, the dangers of an extension of the carious process through the spaces in a diploic mastoid will be reduced to a minimum or entirely abolished. In place of the chisel, spoon or gouge, an electric burr may be employed to both open the mastoid cortex and exca- vate its interior, but while it has been employed to a consid- erable extent abroad, it has not received much encourage- ment as yet in this country, although no very serious objec- tions have been urged against it, and in some cases it is undoubtedly very efficient to remove the osseous tissue in this particular operation. Its virtues for this purpose having been promulgated by Lombard, who states that by its use one avoids the shock of the blow from the mallet which is inevi- table when the chisel is employed, the operation is more rapid; the bone cavity can be made smooth, with no angles, asperities or scales, and it is more exact, as it does not slip as easily as the chisel and gouge, while if it should slip, the results are not serious. Further than this, there is no risk of wounding parts that should be protected, as the facial 272 Suppuration of the Middle Ear. nerve, the semicircular canal, the meninges and sinus, while if any one of these should be reached, the spheroidal form of the burr pushes the tissue ahead without cutting or wound- ing it. If the apophysis is eburnated, he states that the burr is always successful if properly used with sufficient force, and it is especially useful in separating the sinus wall from its osseous canal; the objection that has been raised against it, that it becomes overheated and destroys the tissues, being not borne out in actual experience, as the necessary pauses during the operation allow it to become cool. During the excavation of the mastoid interior, more or less bleeding from the diploic bone surrounding the pneu- matic spaces and from the curetting of granulation tissue always takes place, but in the great majority of cases this is speedily controlled by pressure with gauze sponges, either dry or wet, with a hot antiseptic solution. In a few in- stances, however, this bleeding may be quite severe and prove most annoying, when it is necessary to temporarily stop the operation from time to time and pack the cavity made in the osseous tissue with gauze. This packing or the application of very hot sterile water will in nearly all such cases control the hemorrhage, but in a small class, the oozing from the bone surfaces will continue to the end of the opera- tion almost irrespective of what is done to control it. After all the diseased tissue has been removed and the operation completed, the haemostats are removed, and as a rule the pres- sure and torsion of the larger vessels will have effectually sealed them, but if any should persist in bleeding, they should be ligatured, preferably with fine gut. The bleeding being entirely controlled, the parts may then be irrigated or not as may seem most desirable in the particular case. If but little pus or carious bone has been found, the dressings may be applied after the parts have been cleansed with gauze sponges, but in the majority of cases this will not be suffi- The Simple Mastoid Operation. 273 cient and irrigations are required. For this purpose a phys- iological salt solution, carbolic, boracic or bichloride of mer- cury solutions of weak strength may be employed by syring- ing through the retro-auricular wound and allowing the solu- tion to flow through the antrum and tympanum out from the external canal. Should bichloride be used, either in a i to 5000 or stronger solution, care should be taken that it does not flow through the Eustachian tube into the pharynx, for if this should occur, it will irritate these parts to such an extent that the patient will suffer a great deal of distress for a day or more. Probably the most satisfactory solution for irrigation is the saline solution mentioned, or warm sterile water. After the field of operation has thus been thoroughly cleansed, it must be decided as to whether the wound should be entirely closed or be packed so that it will heal by granu- lation. If it has been small and the opening in the bone has been made of corresponding size and one is sure that all diseased tissue has been removed, there are no reasons which should prevent the closure by sutures at once, so that healing by primary union may take place. For this purpose silk or silkworm gut is best and the edges of the incision should be brought into as close apposition as possible in order to get a good cosmetic result. In the great majority of cases, how- ever, where this operation is performed for chronic otorrhcea, the primary closure of the wound is inadvisable, as one can- not be sure that all diseased bone has been removed, and if, under these circumstances, the entire wound should be sutured, one will probably have a fistula forming in a short time, or it will be necessary to perform a secondary opera- tion to relieve the retained secretion. In these cases it is therefore advisable, if the incision be large, to place one or two sutures in its upper angle and also in the secondary horizontal incision if such has been made in order to obtain 19 274 Suppuration of the Middle Ear. a smaller cicatrix and to prevent a slight drooping of the auricle which sometimes takes place if this be not done, the rest of the wound directly over the cavity in the bone then being packed, so that if later areas of carious or necrosed bone should be found they can readily be removed without again dividing the soft tissues. The method of Blake of allowing the bone cavity to fill with blood clot has been employed in a few cases, but as a rule it is not desirable. This is employed in cases where the opening in the bone is small in size and when the inner wall of the mastoid remains intact and is recommended by the author as a substitute for packing and healing by granula- tion. It is essential to the success of this method that all diseased tissue should be removed and the cavity is then allowed to fill with blood and when partial coagulation has taken place the wound is sutured in its entirety, or the edges of the wound are brought into apposition and by the applica- tion of fairly firm pressure it is allowed to heal by first inten- tion. Healing then takes place by the formation of granula- tion tissue protected by the clot without reaction, and at the same time it is claimed that the time of treatment is much shortened, but in some cases, however, the blood clot is apt to become infected and break down, so that healing will have to ultimately take place through the open wound by granu- lation. When the wound is not sutured in its entirety, but only its upper and lower portion, a rubber drainage tube may be placed well into the small bone cavity, as it is only in cases where the opening in the bone is small that drainage by this method is applicable and the dressings are applied over this. In the majority of cases, however, this method of drainage is not serviceable, and the opening in the bone should be packed with gauze. After cleansing and drying the tissues, the cavity is lightly dusted with iodoform and packed with strips of iodoform gauze, the packing, however, The Simple Mastoid Operation. 275 not being too tight and a narrow strip of the gauze packing being allowed to project between the edges of the wound. The external auditory canal is then lightly packed in the same way so that drainage will be encouraged and not in any manner obstructed. The mastoid is then covered with several layers of iodof orm gauze ; this in turn is covered with a thick layer of plain sterile gauze ; over this is placed a thick layer of cotton, which also covers the entire ear, and the dressings are then held in place by a muslin or gauze bandage so that the parts are thoroughly protected. Opinions vary as to results obtained in curing the otor- rhcea by this operation, some otologists believing that a per- manent cure is seldom obtained by this method, but if it be used in a small selected class of cases of chronic aural sup- puration, as previously described, one will obtain very satis- factory results in a considerable proportion of cases, depend- ing upon the thoroughness with which the limited area of diseased tissue is removed, for even in the radical operation one is apt to be disappointed in obtaining a perfect cure in many cases, Schmiegelow's cases showing this quite clearly, as in ninety-six cases the mastoid apophysis was alone opened in twenty, with 55 per cent, cured; the attic was opened in fourteen cases with seven cures and three improved, while in fifty- three cases the entire middle ear was opened, with 70 per cent, of cures. The continuation of the otorrhoea following this operation may result from several causes, of which the principal is the failure to remove all the diseased bone, but in some this results from performing the operation before the removal of the carious ossicles, and while in such cases the diseased tissue in the antrum and mastoid process may be thoroughly removed, the tympanic suppuration will continue until an ossiculectomy has been performed, when it will usually yield, thus implying in these cases that the tym- panic contents should be removed at first, when this failing, 276 Suppuration of the Middle Ear. the mastoid operation should be performed. Finally, in cases of chronic suppurative otitis media, should both ossiculec- tomy and simple opening of the mastoid process and antrum fail to bring about the cessation of the purulent discharge, the evidence is then in favor of a more extensive area of caries and necrosis than originally supposed and exenteration of the tympanic and mastoid contents must be performed. CHAPTER IV. THE RADICAL MASTOID OPERATION, 277 THE RADICAL MASTO1D OPERATION. While any operative procedure which is performed for the cure of chronic suppurative otitis media is based upon the removal of all the diseased tissue, the radical operation in any of its various forms or modifications, does no more than this, but has the advantage over operation via the canal or the simple opening of the antrum, that one is more certain that all diseased tissue keeping up the suppuration has been removed, and if not, the dangers of extension have been greatly lessened, while the patient has been placed under such favorable conditions, that the tympanum and its neigh- boring spaces are freely opened to local treatment through the meatus or post-auricular opening. As a result of the better understanding of the pathology of chronic otorrhcea, and especially with the knowledge that the antrum and mas- toid cells are involved in practically all cases of long dura- tion, the radical operation has to a great extent supplanted more conservative measures as the simple opening of the antrum, for, as has been shown by Macewan, after the open- ing of the mastoid antrum at its usual position, further pro- cedures have purely a pathological basis, and if the disease 279 280 Suppuration of the Middle Ear. revealed be extensive, so must also be the operation. Al- though the tympanic exenteration has been designated the radical operation, yet actually this is only relatively so, as it may be impossible to remove all the diseased tissue that may extend to the finer cellular spaces in all parts of the temporal bone, and while in the majority of cases sufficient of the dis- eased tissue may be removed to obtain a permanent cessation of the purulent discharge, yet in many instances failure of necessity must take place. As stated by Green, the tympano- mastoid exenteration, that is, the evisceration of the interior of the bone by making the mastoid cells, antrum, tympanum, attic and meatus one large cavity with smooth and healthy walls by removing the external cortex of the mastoid, its entire cancellated structure, the posterior wall of the meatus, the membrana tympani and ossicles and outer wall of the epitympanum is the most valuable operation for the cure of chronic suppuration here and it is also one of the most com- plicated operations in surgery, as its success depends upon the attention to the most minute details, not only in the oper- ation itself, but in the after treatment, the great technical difficulties being the thorough cleansing of the exenterated cavity, the covering of the exposed bone surface, the keep- ing down of exuberant granulation tissue, and the epidermi- zation of the newly formed cavity. Whatever be the nature of the radical operation performed, the object to be aimed at is the same in all, that is, the throwing together of the involved parts into one large cavity lined with a nonsecreting dermoid covering. The indications for the radical operation are usually definite in the presence of serious symptoms from the exten- sion of the suppurative process, but when the question con- cerns only the cure of the otorrhoea, great difficulty will often arise in deciding when to operate and the nature of the opera- tion to be performed. Jackson recommends radical opera- The Radical Mastoid Operation. 281 tion in the absence of mastoid symptoms when the suppu- ration has failed to yield in three months after ossiculectomy followed by "wick drainage." Manasse and Wintermantel are slow to employ the radical operation in the absence of vital indications, while Schwartze believes that it is indi- cated as a prophylactic against fatal results developing with- out any visible inflammation of the mastoid and without signs of pus retention, whenever it is proven that the seat of the suppuration is not limited to the tympanum. While each case must be decided upon the particular conditions present, both from an intrinsic and extrinsic point of view, yet certain indications when present strongly suggest the necessity for radical operation, these being more or less marked in various cases. As regards the pathological changes in the temporal bone, the presence of caries, as shown by the recurrence of granulation tissue after its removal, fistula in the mastoid process, antral suppuration, paralysis of the facial nerve, acute mastoiditis during the course of the tympanic suppuration and suppuration resisting other treatment, indicates the necessity for the removal of the diseased tissue in its entirety. Narrowing or actual strict- ure of the external canal leading to pus retention, or the presence of cholesteatoma of the antrum or mastoid undoubt- edly indicates operation. Politzer does not advise radical operation simply to check a stubborn otorrhcea, because, while the operation may be harmless, there is a possibility of injury to the neighboring parts, of a total loss of hearing, and also that the time required for healing the parts places the patient hors de combat for several months. Cumberbatch sums up this matter quite satisfactorily when he states that the opera- tion should be performed when a frequent recurring dis- charge is invariably preceded by malaise, slight headache, rise of temperature and occasionally mastoid tenderness and discomfort; in cases where previous suppuration has been 282 Suppuration of the Middle Ear. present, but has given no trouble for years, with suddenly developed marked labyrinthine vertigo, due to the spread of the inflammation to the labyrinth, or pressure from some accumulation in that region; in cases of intermittent dis- charge, with masses of sodden epidermis in the meatus, often hiding small granulations, and where syringing constantly removes white shreddy patches and the usual methods of treatment fail to cure; and finally, when there are periodic attacks of mastoid pain commencing after all signs of active mischief in the ear have ceased, and where by exclusion of superficial neuralgia it is possible to determine the existence of sclerosing osteitis. Ballance states that in another class of cases with no mastoidal or other signs, in which removal of the ossicles, antiseptic dressings, etc., fail, and the dis- charge, either offensive or odorless, persists, a wide expe- rience is the best guide, as no definite indications can be formulated, while Lucae in such cases believes that when one is in doubt, it is better to operate, and Grant thinks the responsibility is greater in deciding against than in deciding in favor of the operation. Koerner has pointed out that the radical operation is indicated as soon as the diagnosis of chronic suppuration is made and when the diagnosis of bone involvement is uncertain, the operation should be done as soon as there are symptoms of pus retention, while Dalby has summed up these indications as follows: (i) Undoubt- edly where septicemia has commenced. (2) Undoubtedly where dead or carious bone in the tympanic cavity is accom- panied by ominous symptoms often repeated. (3) When- ever there is evidence of mastoid disease of longer or shorter standing. (4) In a certain proportion of cases where there is dead or diseased bone, but a very doubtful history of ominous symptoms. (5) In a certain proportion of cases with intractable otorrhcea, where no bone disease can be found and no history of ominous symptoms. EXPLANATORY NOTE TO PLATE XXX. This plate shows the completed radical (Stacke-Schwartze) operation on a bone specimen. i, Mastoid antrum and attic opened and aditus ad antrum enlarged; 2, region of horizontal semicircular canal ; 3, bony spine remaining after the removal of the osseous posterior canal wall ; 4, the floor of the external auditory canal ; 5, terminal (tip) cell ; 6, cells opened at the root of the zygomatic process. 284 PLATE XXX The Radical Mastoid Operation. 285 The objects of the radical operation essentially consist in throwing all the middle ear cavities into one (see plate XXX), of removing all the diseased tissue of whatever nature, and of rendering the cavity so formed readily accessible to treatment, thus promoting both the rapid and fairly certain cessation of the suppuration. Certain advantages are also obtained in this way that render it practically the ideal operation for the cure of the tympanic suppuration. By throwing these cavities into one space it exposes the previously diseased areas to the sight of the operator and allows him to immediately destroy any new focus of disease which may subsequently form, either of the lining membrane or of the osseous walls of this cavity ; the parts may be kept in a more aseptic condition than can be obtained in any of the other operations previously dis- cussed, and further, its advantages over operative treatment by way of the canal consists in the facility by which one is enabled to obtain a strong barrier against the extension of the purulent changes to other parts. Over the simple open- ing of the antrum it allows one to remove all the macroscopic diseased tissue and to have perfectly under control any further marked morbid changes, such as small areas of caries, or the throwing off of a larger or smaller sequestrum which may take place, or more extended pathological altera- tions occurring in the bone which had not been removed at the time of operation. By opening the parts in the manner to be later described, anatomical conditions are produced which most materially diminish further risks of purulent retention. While in some cases it may be possible to remove the cause of the suppuration by way of the canal, yet on account of its location this may be extremely hazardous, and as a matter of safety, the radical opening of the mastoid may be necessary, and even should this method fail to produce a nonsecreting lining to the newly made cavity, it possesses the advantage that the patient is left in a much safer con- 286 Suppuration of the Middle Ear. dition than before, inasmuch as the parts can be locally treated with considerable accuracy and all foci for purulent collection and retention can no longer exist. In considering the conditions which may seem to indicate the radical operation, especially when the aural lesions do not appear to be extensive and the symptoms are not well marked, one must always bear in mind that under these con- ditions the operation possesses certain disadvantages which may militate against its performance. Such is the case when the social condition of the patient prevents him from being self-supporting for weeks, or possibly several months, as this operation necessitates in many cases the relinquishment of labor for that time, and again, if the patient depends for his livelihood to any extent upon his hearing, this will have to be seriously considered, as it is not at all uncommon to have the hearing seriously impaired following operation. While a question that must always be considered in such cases, is that in this operation there is always a considerable pro- portion of failures as regards the cessation of the suppu- ration, and the patient should be fully advised of this previous to the performance of the operation. These disadvantages of course do not in any manner apply to those cases where the patient desires to obtain relief from the otorrhoea when symptoms of serious importance are also present, but it is only in the absence of these that such questions will arise. In this chapter two forms of the radical operation will be considered, the various modifications being described later, and of these the Stacke or the Stacke-Schwartze must be selected by the conditions present in each case, many oper- ators preferring the former, but possibly more see greater advantages in the latter. While it is almost impossible to estimate their relative value as compared one with the other, on account of the pathological complex in each case operated upon, yet some idea of their relative value may be obtained The Radical Mastoid Operation. 287 by the statistics of Milligan, who had sixty-five recoveries in seventy-eight Stacke-Schwartze's, while in the former there were forty-seven recoveries in seventy-two operations. In the Stacke operation the antrum is entered from in front of the posterior canal wall backwards, while in the other pro- cedure, which is sometimes also called the Zauf al method, the antrum is opened in the usual manner through the mastoid process, as will be later described. The method recom- mended by Stacke for the radical cure of the chronic aural suppuration consists in making the usual incision over the mastoid process, in detaching the external cartilaginous canal and auricle and chiseling away the postero-superior osseous wall of the auditory canal with the external attic wall, so that both the attic and antrum are freely exposed, and these parts are thrown into one large smooth cavity without any osseous projections. Thus this operation is performed within the osseous canal, and by removing con- centric layers of bone the operative field may be enlarged to any extent desired, dependent entirely upon the extent of the morbid changes which are found and the involved cel- lular spaces are cut away until healthy bone is reached, when flaps are then made from the cartilaginous canal, both in order to obtain a healthy nonsecreting epithelial surface over the newly exposed bone and to prevent cicatricial con- traction of the auditory canal, the after treatment being con- ducted through the meatus to the large cavity which is under observation in all its parts. This method possesses certain advantages, as it gives full ingress to the deeper parts when the cartilaginous meatus has been removed, and one then obtains a maximum amount of space in which to remove the diseased bone and enter the attic and antrum, while the ossicles or their remains are readily extracted. The Stacke operation should be preferred when the groove of the lateral sinus projects far forward, as one practically keeps away 288 Suppuration of the Middle Ear. from danger under these conditions, while in the Schwartze operation, under such circumstances, the danger of wound- ing the sinus is greatly enhanced, or in some cases for this reason the latter method of opening the antrum becomes impossible. While the general indications for the radical operation have been described, certain special indications exist which are in favor of the Stacke method. While Politzer states that this operation is too radical for the removal of the ossicles alone, which is undoubtedly true, it is far superior to intra- aural methods for removing granulations and cholesteato- matous masses from the attic and its real indication is in those cases where, besides the ossicles, other parts of the temporal bone are diseased. It is also specially indicated, as before mentioned, when the sinus is pushed forward as the result of an anatomical abnormality or mastoid sclerosis, and when it is only necessary to expose the attic and antrum, as under such circumstances the removal of osseous tissue is small and the damage to the hearing is less than in the more extensive radical operation. When the diseased area is large, the Stacke method is objectional and presents the disadvantage that an excessive amount of tissue is destroyed, and further, it presents the danger of injuring the facial nerve, the horizontal semicircular canal and the stapes. While in many cases this operation is not followed by suc- cessful results, because the carious process is more extensive than is comprehended in the usual Stacke procedure and is not removed in this manner, although this can hardly be cited as a fault against this particular procedure, but should rather be considered as the result of an error in diagnosis, whereby the post-aural operation was not performed origi- nally in such cases as it should be. For cholesteatomatous masses, limited to the attic and antrum, this procedure is well suited, as it leaves no permanent external wound, and yet by The Radical Mastoid Operation. 289 cutting away the external wall of these spaces one is in a position to inspect and treat the exposed spaces. But when a large defined cholesteatoma is present, involving not only these parts but also the mastoid process and possibly ex- posing the meninges, this operation alone will not suffice for its cure, and in such cases the Stacke-Schwartze procedure should be adopted, so that the parts may be carefully observed through the permanent retroauricular opening. While the Stacke operation is applicable in many cases, as already out- lined, it should not be employed when the carious process of the mastoid has extended to the surface and resulted in a fistula, or when there are well-defined symptoms of a mastoid abscess. While in cases where it is supposed that the destruc- tion of the mastoid interior is very extensive, even if but slight symptoms be present, or in those cases where the ex- ternal auditory canal has been greatly narrowed or an actual stricture exists, some other form of the radical operation should be employed in preference to the Stacke. The primary step in the Stacke operation is the incision through the soft tissues over the mastoid process and differs but little from that already described for the simple open- ing of the antrum. The incision should be curved, com- mencing anteriorly at the temporal region slightly above the auricle and should be carried downwards close to the pinna, to a point about a centimeter below the tip of the mastoid process. It should cut through all the overlying tissues down to the bone. At its upper extremity this is sometimes mod- ified by dissecting loose the soft parts above the temporal ridge superficial to the temporal fascia, and from the ridge downwards, the original incision which in its upper ex- tremity should extend only through the skin and superficial fascia, the first incision is extended through the periosteum and slightly along the temporal line, so that a triangular flap of the periosteum is thus made which can be readily pushed 20 290 Suppuration of the Middle Ear. forward to the edge of the osseous canal. After the bone has been exposed the periosteum of the anterior flap is pushed forward with the elevator, so that the canal and posterior portion of the zygomatic root is clearly exposed to view, and with it the dermal lining of the cartilaginous canal. With a small elevator the periosteum is separated from the walls of the auditory canal as far into the meatus as possible, and when this is done, it will be found that the soft tissues of the canal have been entirely detached from the underly- ing bone, except at their inner and anterior portions. With a small knife the entire canal is divided transversely as near the membrana as possible. By then drawing the auricle out- wards and forwards the still adherent anterior attachments may be severed, and the entire cartilaginous canal, including the auricle and a considerable portion of the inner dermal lining, may be drawn completely outwards, so that the osseous portion of the canal and the tympanum are free and readily seen. The auricle with its attached canal is then held for- wards and out of the way with a retractor and the remnants of the membrana tympani with the malleus are then removed in the manner previously described, if they have not pre- viously been removed by operation through the canal. If the ossicles are present, at least in part, the incus may also come away at the same time as the malleus is removed, but if this does not take place, then it is advisable to leave the former ossicle until a later step. A probe, or preferably Stacke's protector, is then held in place in the attic, and then with the gouge or chisel placed a few millimeters above the edge of the epitympanum, holding the instrument used slightly backwards, the bone here is removed while the pro- tector may be used as a guide. The osseous tissue of the external attic wall corresponding to the superior and pos- terior margins of the bony canal, should thus be carefully removed, measuring the depth of the attic from time to time The Radical Mastoid Operation. 291 with a bent probe until the tegmen tympani and the superior wall of the meatus are perfectly smooth and continuous. After the attic has thus been freely exposed, the incus, if present, is removed, and with the protector still covering the stapes, it is pushed backwards as a guide into the aditus and the osseous tissue of the tympanic margin and this angle of the canal is cut away until the probe or the protector can readily enter the antrum. The facial nerve and semi- circular canal are then protected by the instrument, and with the chisel the osseous tissue external to the antrum is cut away. By doing this one removes a part of the cortex and the posterior canal wall in its lateral portion and thus con- verts the antrum into a narrow trough which forms a single large cavity with the auditory canal and attic. In removing this area of bone external to the antrum, quite large pieces may be cut away with the chisel and all the bone should be obliterated here, so that the lower wall of the antrum becomes continuous with the inferior wall of the external canal. While performing this part of the operation, one has gained from the removal of bone in entering the antrum a knowl- edge of its position and size and therefore can work with a great degree of confidence, and when this cavity has been thrown into one with the canal, its upper and lower osseous walls will be smoothly continuous with those of the latter. The small spur which guards the entrance between the attic and antrum should be made perfectly smooth and the facial prominence or spur must in part be very carefully lessened in size until it becomes assimilated, as it will laterally in the lower canal wall. In exposing the attic, as has been shown by Hartmann, it is necessary to penetrate the supero- posterior wall of the osseous canal, rather than the posterior, which is too near the facial canal to permit of free incisions, but in regard to the facial nerve and semicircular canal, it is desired to consider them later, after describing the Stacke- 292 Suppuration of the Middle Ear. Schwartze operation in connection with their relation to the radical operation in general. After the tympanum, attic and external auditory canal have been exposed and made to com- municate with each other, as described, the pathological tis- sue is removed with the curette, care being taken to avoid the stapes when the tympanic cavity is being curetted, and if caries is present on the tympanic floor, the ridge of bone here should be broken down and the hypotympanum carefully curetted. The mastoid cells are then broken down, if such be necessary, and the diseased tissue in all parts of the large cavity thus formed should be thoroughly removed, and any irregularity of its walls obliterated, when the plastic portion of the operation should be performed, as will be later de- scribed in connection with the plastic methods of the Stacke- Schwartze operation. The Stacke-Schwartze operation, which is a combination of the Stacke method and the opening of the mastoid antrum through the cortex, the antrum being opened in the usual manner, and after the posterior wall of the auditory canal has been removed, the cavities are thrown into communi- cation after the method of Stacke, the membranous canal not being entirely withdrawn from the canal but its anterior half is allowed to remain undisturbed, the objects of this operation differing in no way from that of the former of removing all the pathological tissue and throwing the affected cavities into one chamber, but its method of doing this varies, as will be seen. When the diseased process is somewhat extensive, this procedure possesses the advantages over the Stacke and other similar operations in that it furnishes a large space in which to operate, giving the maximum amount of space that can be obtained here, and it also enables one to freely determine the extent and character of the tissue changes in the antrum and mastoid process, so that one can very accurately ascertain the amount of morbid tissue which The Radical Mastoid Operation. 293 it may be necessary to remove. If the lateral sinus be not too far forward, it enables one to more safely and thoroughly expose the sinus if parts of its osseous walls be carious and the same advantages are also to be noted in removing the tegmen tympani or carious bone in its immediate vicinity, while in many cases a more satisfactory plastic operation can be performed after this operation than with the Stacke procedure. The thoroughness with which the diseased tissue can be removed and the cause of the chronic suppurative otitis media be eradicated makes this a most favorable opera- tive procedure for such cases, and by many otologists it is considered the radical operation par excellence. Compared with the other radical procedures, the following steps are carried out in performing this operation: the exposure of the operative field, the removal of the posterior-superior lining of the external auditory canal, opening the antrum by entering the mastoid process through the usual situation on the cortex, and by removing the posterior wall of the osseous canal, the extirpation of the external wall of the attic, the removal of the tympanic and mastoid contents and throwing these cavities into a single uninterrupted space, and finally the plastic method and dressing of the wound, including skin grafting or not as may be necessary in the individual case. The primary incision over the mastoid varies to some extent in the hands of different operators, but the principle involved in all is to obtain a free operative field by a liberal dissection of the soft parts. As a rule the incision should begin immediately above the superior attachment of the pinna, and extending three or four millimeters behind and parallel to the auricle, should reach the tip of the mastoid. It should be made slightly concave in the anterior direction and at its beginning over the temporal muscle, it should extend only through the skin and superficial fascia, as 294 Suppuration of the Middle Ear. nothing is to be gained by cutting into the muscle and trou- blesome bleeding takes place, which may be productive of considerable annoyance, while further down over the mas- toid process the incision should extend to the bone. As in- sisted on by Politzer, the incision is carried down near the insertion of the auricle over the meatus, and the knife should be held at right angles to the planum to avoid cutting the posterior membranous wall of the auditory canal, for if this should be thus accidentally damaged, the proper plastic oper- ation cannot be performed. This is liable to happen quite readily, as when the auricle is pulled forwards, as may some- times be done to put it on the stretch for the incision, its line of insertion is pulled more anteriorly, the incision being made so that the skin, with the subcutaneous tissue and the posterior muscular fibers of the auricle are cut through, in- cluding the periosteum, or this may be cut through by a second incision. Again, the incision may be made so that its upper end is above and then in a direction downwards to slightly above the tragus, while its inferior extremity is brought forwards around the lobule and is made to terminate immediately below the antitragus, but this leaves a some- what conspicuous scar, which should be avoided as much as possible in operating. When the entire mastoid surface back, near the middle of the mastoid and extending a cen- timeter or more above the temporal line to the same dis- tance below the tip of the mastoid, and from the upper end of this incision a second horizontal incision is made, extend- ing three or four centimeters both anteriorly and posteriorly, so that by turning backwards and forwards these flaps, com- posed of both the skin and periosteum, the entire mastoid cortex is exposed. When the incision previously described is employed, it is necessary, if sufficient room has not been obtained, or if the skin over the mastoid is much thickened from inflammatory infiltration, to make a second incision The Radical Mastoid Operation. 295 backwards at right angles to the first, or if this be not desired, the original incision may be enlarged, both above and below. One should be cautious in making the original incision that it should not be placed too close to the insertion of the auricle, for fear of not obtaining sufficient exposure of the anterior edge of the mastoid, for if this be done, it will be necessary to make another incision at right angles to this one, or to undermine the posterior flap, which is very unsat- isfactory and rarely give sufficient room for working. In all cases the upper end of the incision should be inclined in a horizontal direction or somewhat forward and downward over the top of the insertion of the auricle, so that the upper wall of the osseous meatus will be thoroughly exposed, and this is also necessary in order to obtain sufficient room to remove the external epitympanic wall. In certain cases it may be necessary to modify the original incision, the most frequent of these local conditions necessitating this, being described by Politzer as follows : ( I ) In diffuse fluctuating subperiosteal abscesses, before making the incision, he evac- uates the pus with a trocar and cannula and washes out the abscess cavity, while after incising the soft tissues, the gran- ulation tissue in the abscess cavity is scraped out with a large sharp curette before the chiseling of the osseous tissue is commenced. (2) If there is a fistula on the mastoid process, the incision, if possible, is made through it, and after the soft parts are dissected free the callous edges of the fistula are excised with curved scissors. (3) When it is found that there are abnormally firm adhesions of a much- thickened, tendinous-like periosteum to the planum mas- toideum and the circumference of the external auditory canal, it is seldom possible to loosen the periosteum with the sharp elevator and to avoid tearing it should be carefully dissected away from the bone with a scalpel and forceps. After the incision through the soft parts has been com- 296 Suppuration of the Middle Ear. pleted, the periosteum of the posterior flap is separated from the bone and pushed backwards, while with the elevator the periosteum of the anterior part of the mastoid is handled in the same way, so that the planum mastoideum is perfectly free. The anterior periosteal flap should be freely dissected up until the landmarks previously described are readily seen and the spina with the postero-superior wall of the osseous canal are entirely clear. In some cases, where the perios- teum is somewhat thick and adherent at this point, it will be almost impossible to push it out of the way as desired, and it is often necessary to make a small horizontal incision through the fibrous tissue directly above this point, so that it meets posteriorly the original vertical incision and the periosteal flap thus obtained can be readily pushed aside in order to have a clear operative field. When the perios- teum has thus been pushed aside and the wall of the meatus becomes visible, a narrow elevator is introduced into the osseous external canal and the membraneous meatus is de- tached from the bony wall at its superior and posterior por- tion, until it is entirely free at these parts clear to the tym- panic membrane. To accomplish this the cartilaginous canal and auricle should be drawn well forwards, so that the tissues may be cleanly stripped from the bone and the inner ex- tremity of the membraneous tube seen in order that the next step of the operation may be readily accomplished. The fibrous meatus, which is then drawn well forward and out- ward, is divided at its posterior part with a straight sharp knife, as near to the annulus as possible, or this may be accomplished by the use of an angular knife, cutting from within the meatus posteriorly. Another method of sepa- rating the membraneous meatus at this point is accomplished by making an incision in the upper anterior wall of the meatus, commencing at the annulus tympanicus and from within outwards ; a like incision is then made along the lower The Radical Mastoid Operation. 297 part of the posterior meatal wall, parallel and opposite to the first incision and the flap of tissue thus included between these two incisions is separated from the osseous wall and removed with scissors, so that the posterior and superior walls of the canal are thus exposed. This method may, however, seriously interfere with any plastic operation that may be desired, and for this reason seems to be usually unde- sirable. A further method, which is somewhat extensively employed and which obviates the cutting of the canal wall, consists in making firm but careful traction upon the mem- braneous meatus, so that the canal may be separated at its inner superior and posterior extremity with the aid of the smallest elevator, so that it becomes detached at the parts indicated very close to its insertion at the annulus. Unlike the Stacke procedure, the canal must not be detached at its inferior and anterior relations with the bone, as in this opera- tion it is entirely unnecessary and from these two points it is desired that the eviscerated tympanum and other cavities should receive their epidermal lining, the spreading of the epidermis for this purpose taking place from the canal at these points. After the canal has thus been separated from these walls of the osseous meatus, it should be held well forward against the anterior wall by a narrow retractor placed between it and the posterior wall, and when the bone of the mastoid and the posterior canal wall have been removed well inward, this may be removed and the usual retractor for the anterior flap is employed in its place. If this is not desired, some operators prefer to hold these parts away from the operative field by passing a strip of tape or gauze through the canal and holding it out of the way in this manner, which is usually satisfactory if the walls of the membraneous canal are fairly normal, but should they be inflamed or much mac- erated from the purulent secretion, this method of retrac- tion cannot be employed for fear of tearing the soft tissue from the force necessary to keep them drawn well forward. 298 Suppuration of the Middle Ear. The osseous field being then freely exposed and the supra- meatal triangle being taken if possible for the guide, the mastoid is entered as in the simple operation until the antrum has been opened, or instead of confining the removal of the osseous tissue to this space alone, the bone may be chiseled away from this position in a direction forward and embrac- ing the posterior wall of the anditory canal, the removal of the bone being continued until the groove in the bone thus formed unites the antrum with the tympanum and external surface and the remains of the tympanic membrane can be seen. It is unnecessary to redescribe the method of open- ing the antrum without breaking down the posterior canal wall, as this has previously been done, and it differs in no way from that mentioned, the removal of the posterior wall, however, from this side being the characteristic feature of this operation. Should the mastoid cortex show a softened area of bone or a fistula, it is the habit of some operators to commence the removal of bone at such a point and then work towards the antrum, but this is not always advisable, and as has been previously stated, it is always best to enter the antrum at the point of election, and after this has been accomplished, attention may be directed to the external lesion during the course of the mastoid evisceration. Should the surface of the process show no lesion, which is by far the usual condition in these chronic cases, one may with the straight and curved chisel remove the bone over the region of the mastoid and supero-posterior wall of the canal, with the small area of the opening in the bone above and then by re- moving successive layers of bone, the antrum may be entered and this portion of the canal wall broken down as desired, so that as the opening is made deeper into the bone, the parts are constantly kept in view. This should form a somewhat cone- shaped opening, with its apex directed inwards and somewhat forwards, and as the antrum in its external boundaries EXPLANATORY NOTE TO PLATE XXXI. This plate shows the partially completed Stacke-Schwartze operation. The course of the facial nerve in its bony canal and its relations to the tympanic cavity and its contents is well shown. i, Facial nerve; 2, incus; 3, stapes; 4, the remains of the membrana tympani, showing the handle of the malleus and its short process ; 5, the remains of the pos- terior osseous canal wall. 300 PLATE XXXI The Radical Mastoid Operation. 301 usually is met with somewhat inward to the middle of the posterior wall of the bony canal, one should carefully watch for it in this situation. When the antrum has been opened in the usual manner, the next step is to remove the posterior canal wall with chisel, gouge and cutting forceps. The bone is best removed here in small wedge-shaped pieces above a line corresponding to the base of the orifice in the mastoid and the floor of the aditus; the bridge of bone formed by the posterior wall, in other words, being broken down to a level with the floor of the osseous auditory canal, for about two-thirds of its distance inwards. This part is made con- tinuous with the opening in the mastoid process for the dis- tance previously mentioned, as the inner third cannot be completely removed in this manner on account of the danger to the facial nerve. When the opening in the antrum has been made a bent probe or Stacke's protector is passed into the attic, and using this as a guide and guard for the canal and nerve, the wedge of bone mentioned is thus cut away. Great care should be used in removing the inner section of the posterior meatal wall, and after this has been done, the tympanic cavity should be entered by the removal of the external attic wall, or that part of it which still remains. This may be done with a narrow chisel, or if the bone be carious in part, with the curette, or the forceps chisel may be employed. The projecting or overhanging ledge of bone here should be entirely removed, including any small pro- jections or recesses in the bone, until the parts have been made smooth and the surface is directly continuous with the roof of the tympanic cavity. The osseous tissue here should be so cut away that when the probe or protector is used it can be withdrawn directly outwards on a plane with the superior wall of the external canal, without encountering any resistance. Sometimes a few spicules of bone remain where the posterior wall has been removed and catch the 302 Suppuration of the Middle Ear. protector as it is being withdrawn ; these should be removed with the chisel, so that communication between the various cavities is entirely free. The thin plate of bone which may now remain at the inner end of the posterior canal wall is then carefully removed in the same manner, so that if there be not too much morbid tissue in the tympanum, both the oval and round windows may be seen. As this small area of bone lies immediately below the prominence of the facial canal, extreme caution must be used in removing it, but with care this may readily be done without damaging the nerve, and as it forms in part the posterior tympanic space where purulent material is apt to be retained, it should not be allowed to remain (see plate XXXI). All that now remains of this part, and which obscures to some extent the hypotym- panic space, is the spur of bone through which the facial nerve passes in this part of its course. This should be very cautiously smoothed down by removing thin layers of the bone with a small sTiarp chisel, and at the same time having an assistant watch the patient for any signs of irritation of the nerve, while the chiseling is continued until the sharp spur of bone has been smoothed away. If the ossicles have not already been removed or de- stroyed during the suppurative changes, they may now be readily extracted, although it is sometimes advisable to remove the malleus, incus and remains of the tympanic mem- brane through the canal as a preliminary step of this opera- tion. The advantages of doing this before the osseous tissue has been somewhat extensively broken down are that the relations of the parts are more easily recognized, and if the ossicles are left until a later stage of the procedure, they are apt to be obscured by the blood which drains in the deeper part of the wound, and their extraction may be somewhat difficult. In many cases, however, this question will not be presented, as these bonelets have previously been removed The Radical Mastoid Operation. 303 through the canal in an endeavor to cure the tympanic sup- puration. Small, straight and curved curettes are now used to clean the tympanic cavity, aditus and antrum of granu- lation tissue, cholesteatomatous masses and carious bone, every portion of the larger, single cavity now made being thoroughly cleansed in this way of morbid material. In curetting these parts, care must be taken that too much force be not used on account of the thinness of the walls and the proximity of dangeous parts. It should be borne in mind that the roof of the aditus forms part of the floor of the cranial cavity, supporting the temporal lobe of the brain and its internal wall is in close relationship with the semicircular canals. Particular attention should be paid to the region of the attic and after all diseased tissue has been removed from this part, the roof of the tympanum should be carefully examined with the probe to find any evidences of carious bone which may be present. Attention must also be directed to the anterior and inferior portions of the tympanum, as there are very apt to be small areas of carious bone here which escape observation unless one carefully goes over these parts in detail. If the recess of the lower floor of the tympanic cavity is situated at a lower level than usual, it will be necessary, in order to thor- oughly remove all the diseased tissue here, to cut away the external wall of the hypotympanic space. This may be readily done with a few strokes of the chisel, but unless it seems to be absolutely essential the bone should be left intact, as far as possible, as, if it be removed, it seriously interferes with the growth of the epithelial cells from the canal into the tympanic cavity, which to a great extent takes place here, and as a result of the mass of granulations which form after the small portion of osseous tissue is removed, the epidermi- zation of the cavity is often materially delayed. Usually, however, the floor of the tympanum can be thoroughly cu- 304 Suppuration of the Middle Ear. retted without removing this wall, but care must be taken that the jugular fossa, which, as previously indicated, is in close relation with this part, is not harmed by rough or careless curetting. As in no small part the success of the operation depends upon the thoroughness with which the exenterated cavities are kept from further infection, it is necessary that the ante- rior wall of the cavum tympani receives special attention in order to obviate any danger of contamination by way of the Eustachian tube. For this reason the tympanic mouth of the tube should be obliterated as completely as possible by curetting away any softened bone that may be found, a very small curette being necessary to get well into the mouth of the tube, and care must be taken in removing the osseous tissue on account of the close relationship of the tube at this point with the internal carotid artery. All granulation tissue must be removed, both in and around the opening of the tube and the mucous membrane lining its orifice should be entirely removed, so that the growth of healthy granulation tissue and the subsequent cicatricial contraction will entirely oblit- erate it. Should this not be accomplished, a redevelopment of granulation tissue soon takes place at this point, and if the tube thus remains patulous, the otorrhcea will often continue as the result of infection from the nasopharynx. After this has been accomplished and all diseased tissue and carious bone has been removed from the newly formed cav- ity, the next step in the operation is the removal of the mastoid contents, or as much as may be found involved in the suppurative process. While any portion of the temporal bone may be involved in the carious changes or be the seat of a condensing osteitis, the former condition associated with necrosis occurs in the following order of frequency, accord- ing to Schwartze, and the gross lesions may be as a rule found in such locations: the mastoid process, the posterior The Radical Mastoid Operation. 305 and upper wall of the external auditory canal, the roof of the tympanum, the ossicles, the inner wall of the tympanum, the groove of the lateral sinus, the floor of the tympanic cavity, the posterior wall of the carotid canal, the labyrinth, and finally the internal auditory meatus. The extent of the tissue destruction varies in practically every case operated on, Stacke believing that the caries in chronic suppurative otitis rarely is confined alone to the ossicles, and yet at the same time rarely goes beyond the tympanic cavity, but this view can hardly be substantiated after seeing many cases of chronic otorrhcea, as it is not at all unusual to find the mastoid process extensively disor- ganized, an example of this being well shown in a J case of Kirchner's, where, during the course of the operation, the entire mastoid process, with a part of the squamosa, was removed as a large sequestrum. In practically all cases of chronic otorrhcea which undergo the radical operation for the cure of the suppuration, granulation tissue and carious bone are found in the antrum or its immediate vicinity and in a much smaller number of cases the dura is exposed at various points, especially by the removal of a small carious area on the roof of the antrum, while in other instances the tissue destruction exposes the lateral sinus. The extent of the morbid changes and their relation to and association with the symptom complex being well shown by Jenkins in a study of these points in eighty consecutive cases where the radical operation was performed. In each case, in addition to the discharge, one or more of the following symptoms being present: pain in the affected ear or on the same side of the head, vertigo, nausea, vomiting and general malaise. In most of the cases there were polypi or granulation tissue in the tympanum, tenderness over the mastoid process, swell- ing of the lining of the external auditory canal, bulging downward of the posterior wall of the canal and the adjacent 21 306 Suppuration of the Middle Ear. part of Shrapnell's membrane, facial paralysis, caries of the ossicles or the presence of roughened bone found by the probe in the walls of the tympanic cavity, the symptoms and phys- ical conditions rarely being found singly, but mostly grouped together in varying proportions. The next step in the operation is the removal of all the diseased tissue in the mastoid, the extent of the removal of the outer layer of bone for this purpose varying with the extent of the morbid changes which are found in the par- ticular case. If this is not extensive, it is usually desirable not to enlarge the opening to too great an extent, as the smaller the area in the mastoid which may be opened, con- sistent with the thorough removal of all morbid tissue, the more rapidly will the parts heal. When the vertical portion of the mastoid is involved or cholesteatoma is present, the opening should be extensive and should be enlarged poste- riorly and inferiorly, and the bone should be cautiously re- moved above if this becomes necessary. On the other hand, when the cortex is carious or a fistulous opening on the sur- face is found, the one should be removed in this direction, ir- respective of the location, until the opening embraces all the parts which may be involved. The principle to be carried out in this respect being that all the surface of the bone over- lying the cells and cavities, should be entirely removed if diseased tissue lie beneath, so that all parts are converted into one large open space, so that when a bent probe is laid against the inner wall of the tympanum, aditus or antrum it may be withdrawn outwards without meeting with the least obstruction. The amount of bone which must be re- moved from the mastoid interior by means of the curette, or with the chisel if hard bone is encountered over a pneu- matic space which is presumably infected, again depends entirely upon the amount of diseased tissue which may be found. Although the mastoid process may appear not to be The Radical Mastoid Operation. 307 extensively involved, it is essential to obliterate all the cavi- ties, including the cellular structure of the process and the cancellated structure of the tip. All prominences or ridges should be removed so that the walls of the cavity which is formed by the tympanum, attic, aditus, antrum, mastoid and external auditory canal, are smooth and composed of hard healthy tissue, inspection being made of the posterior wall of the antrum and that portion in relation with the lateral sinus, which may,be the seat of a small focus of caries, which should be eradicated even if the sinus be exposed. If the bone has not already been removed which overhangs the antrum, this should now be done by again placing the pro- tector over the facial canal and stapedial regions, as it may be necessary to protect these parts and the inner wall of the antrum, and with the chisel the external edges of the bone here are cut away, until it is on a level with the margin of the opening in the mastoid. The parts should be then wiped dry with gauze, all bleeding controlled and all parts of the cavity should again finally be examined to see that the walls are perfectly smooth and no rough places have been left or depressions or projections ignored. If any places are found which are not smooth, even though composed of healthy bone, these must be properly cared for, a few strokes of the chisel usually being sufficient, as the more perfectly the walls in their entirety are made as smooth as possible, the more uni- form will be the resultant granulating surface and the more rapid will healing take place (see plate XXX). When all the diseased tissue has .been removed and the walls of the cavity resulting smoothed down, as described, the next step in the procedure is the placing of the membra- neous canal walls in position by a plastic operation. In either of the so-called radical operations described, some method must be adopted to form an epidermal covering for the newly formed bone surfaces and this may to a great 308 Suppuration of the Middle Ear. extent be accomplished by splitting the membraneous canal and applying the flaps thus made to the osseous surfaces. Alderton believes that it is wrong to turn the skin flaps for- ward from the posterior part of the external cartilaginous canal into the bone wound, as the folding of the skin he claims makes the opening from the bone into the canal smaller and perichondritis, and chondritis of the auricle is apt to develop, while ceruminous collections are apt to occur from the inclusion of these glands in the parts. This opinion, how- ever, is not held by the great majority of otologists, and while he believes that it is much preferable to remove entirely the segment of the soft tissues of the canal wall opposite the bone wound, such a procedure does not seem advisable where the bone wound is at all of any size. The flaps should be formed from the fibro-cartilaginous canal and in part from the concha, and while the shape of the flap must necessarily vary in different cases as in some the canal flaps are sufficient to fairly well cover the parts desired, in others it will be nec- essary in addition to this to utilize a portion of the tissue from the concha, in order to thoroughly form a covering for the parts. A satisfactory method of performing this plastic operation is to make a horizontal incision completely through the soft tissues of the membraneous canal at its posterior aspect and extending from where it has been cut away close to the annulus tympanicus, outwards to the root of the auricle. In this manner two triangular-like flaps are formed from which the cartilage may be dissected out or allowed to remain, as may be desired, although if this is done, it is possible to better apply the flaps with more accuracy to the surfaces desired. These are then pressed backwards into the bony cavity in close contact with its walls in the position desired and held in position by tampons of iodoform gauze, or in order to obtain a more secure adhesion, one of the flaps should be sutured to the periosteum behind and above The Radical Mastoid Operation. 309 the osseous opening, while the other flap is sutured to the periosteal tissues below. The sutures should be of cat- gut and in order that they may withstand a considerable amount of tension without tearing through the tissues, they should be inserted at some distance from the cut borders of both the canal flaps and the periosteal surface and should also in addition be passed through the entire thickness of the tissues of the canal. Should the cavity in the bone be such that the flaps formed in this way will not cover the desired space, another method may be employed with con- siderable satisfaction in many cases. This consists in making a horizontal incision in the membraneous canal along the pos- tero-superior wall and extending the same length as the incision described in the previous method, parallel with the axis of the canal. Close to the concha and at right angles to it another incision is made downwards and backwards, so that rectangular flaps are formed instead of those of the triangular shape mentioned, these being placed over the bone surface and treated in the same manner as previously de- scribed. Other methods of performing the plastic operation may also be employed, as will be described in another chapter. In both cutting out the flaps from the canal and in their application to the walls of the bony cavity, care should be taken in the former instance that the cartilage of the auricle should not be subjected to too great an amount of traumatism, or that the incisions should not be made too freely into it, as if this should occur, perichondritis is liable to ensue, with subsequent deformity of the pinna. Also, in applying the flaps to the osseous walls, care must be exercised that too much prominence be not given to the posterior wall of the canal, for should this be done, the auricle, after healing has taken place, will not correspond in position with that of the opposite ear, and as a result of the large cavity behind the position of the membraneous canal, considerable deformity 310 Suppuration of the Middle Ear. will ultimately ensue. This can be prevented, however, by carefully placing the flaps and retaining them in position, and if necessary by cutting away with the chisel a small portion of the superior edge of the meatus. Should the bone cavity be very large, the flaps from the canal will not always be sufficient to cover the parts and a long time will be neces- sary in the epidermization of the wound, but when the cavity is small no advantages are to be derived from additional methods of hastening this process, although under the former circumstances the application of skin grafts by the method of Thiersch is of great practical value. The grafting may be performed as the next step in the operation after the canal flaps have been sutured in position, or some prefer to delay this until the walls of the cavity are covered with a fair amount of healthy granulation tissue; the method of graft-' ing as one of the concluding steps of the radical operation will here be considered, while that performed later will best be described in the chapter on the after treatment of the mastoid operation. As the technique of this procedure, as described by Dench, has proven most successful, it is here given in detail as employed by this author : "The grafts used are taken from the thigh and at the time the patient is pre- pared for the mastoid operation, the anterior and internal surfaces of the thigh are scrubbed with soap and water, then shaved, again scrubbed with a I to 1000 bichloride solu- tion and washed with equal parts of alcohol and ether. Anti- septic dressings are then applied, being kept in place by adhesive straps, a layer of cotton and a firm bandage. When the operation has proceeded to the time for employing the grafts, the dressings from the leg are removed, large grafts are cut and if possible from one and a half to two and a half inches in length. These are removed from the razor to a large spatula with a sharp needle and a few drops of normal saline solution is dropped on the epidermis and the spatula The Radical Mastoid Operation. 311 is also moistened before slipping the grafts on it. Several should be cut so that if one fails to place the first in posi- tion others will be ready. The auricle is then drawn for- ward and a sponge is placed along the cut margin of the anterior flap to prevent oozing into the bony cavity while the graft is being introduced ; the posterior margin of the incision may also be protected in the same way, although this is less apt to bleed. The temporary packing to control the bleed- ing is then withdrawn from the cavity and the spatula, car- rying a large graft, is taken in the left hand and carried com- pletely across the bony cavity, so that the free margin of the spatula rests close to the anterior wall of the meatus. With the sharp needle the edge of the graft is then pushed off the spatula and held against the anterior wall of the meatus, the spatula gradually being drawn backwards so that the graft falls into the bony cavity. This should be done some- what rapidly so that the graft may sink deeply into the bony cavity before the deeper parts become filled with blood. The graft is then applied closely to the internal wall of the tym- panum, to the tympanic roof, the prominence of the Fallopian canal, the horizontal semicircular canal, and should partially line the mastoid antrum. It is then held in place with small pledgets of cotton impregnated with aristol and these are applied by carrying the first pledget downwards, forwards and inwards to force a portion of the graft well into the mouth of the Eustachian tube. The parts are now plugged as rapidly as possible to hold the graft in position, and as its edges always roll more or less after the deeper pledgets are placed, the graft should be spread out more perfectly with a long sharp needle, so as to line the more superficial parts of the cavity, the entire space occupied by the graft being filled with the little pledgets. Should the graft fold upon itself when packing it into position, so that it will not spread out completely over the walls of the cavity, then a second 312 Suppuration of the Middle Ear. graft should be used to complete the lining, as it makes no difference if the grafts overlap or if the second graft par- tially overlaps the cotton packing, for as long as it is brought into contact with the bone walls, the overlapping part or the part not applied to the walls, sloughs, while the remain- der becomes attached. By carrying out this method all the exposed walls of the cavity may be covered and the healing of the parts will be greatly facilitated, while if the diseased tissue has previously been thoroughly removed, the purulent discharge will rapidly cease. In cases where the skin graft- ing is thus made, a strip of sterile gauze is placed on top of the cotton pledgets, with the end brought out by way of the enlarged meatus and the mastoid wound may be closed in the usual manner." In those cases where skin transplantation is not per- formed and the operative procedure has resulted in the re- moval of but a moderate amount of tissue, the parts should be cleansed with an antiseptic solution, such as a I to 5000 or even stronger bichloride solution, or they may be carefully wiped out instead with gauze sponges and then may be dusted with an antiseptic powder or not as may seem best. In such cases as these the incision behind the ear may be entirely closed by interrupted sutures of silk or silkworm gut, so as to obtain perfect apposition and a rubber drainage tube is inserted into the canal so that it goes well into the tympanic cavity and drainage by way of the meatus is obtained. Some- times when the posterior wound is primarily sutured, one may allow the anterior flap to slightly overlap the posterior, as this is supposed to result in a less conspicuous cicatrix and prevents the ear becoming depressed in the enlarged canal or from turning too much outwards, while to prevent a deformity of the meatus which may occasionally follow the displacement of the outer segment of the canal, the drainage tube used should be of sufficient size to fit snugly in the canal. The Radical Mastoid Operation. 313 In however those cases where the operation has been very extensive it appears advisable that the posterior wound should remain open at first and then later it may be allowed to close by granulation or kept free by a retro-auricular opening as may be desired, the latter being especially in- dicated in the presence of cholesteatoma. In cleansing the wound previous to packing irrigations may be used if the purulent discharge has been thin and irritating, or choles- teatomatous masses have been found in considerable quan- tity, as in such cases it is practically impossible to render the parts at all clean without such irrigations, but in the majority of cases and in all in which the dura or sinus has been exposed, irrigation is not necessary, as the cavity can be thoroughly cleansed by wiping it out with gauze sponges. The upper angle of the wound may then be brought together with two or three fine silk sutures, either just before or after the packing has been applied, and if done before, the cavity is thoroughly dried with gauze pads and an antiseptic powder may be dusted over the parts. The tympanum, antrum, meatus and all parts of the mastoid cavity are then packed with small pieces of iodoform gauze and the cavity filled with gauze strips, so that drainage may be obtained both by way of the meatus and the post-auricular opening. The packing should be quite firmly placed in position, but care must be exercised that it does not exert too much pressure over the region of the stapes, as if this is done, unpleasant symptoms may develop, as in a case reported by Herzog, where the pressure of two firm iodoform tampons in the cavity of the middle ear was followed by pseudo-epileptic attacks. Over these dressings the usual dressings, consisting of a pad of gauze and a layer of cotton held in place by a suitable band- age, as described in a previous chapter, is placed. In order to obviate to a great extent the pain from which the patient suffers at the first change of dressings Whiting suggests that Suppuration of the Middle Ear. a piece of Cargile's membrane or thin rubber tissue perfor- ated with small holes be closely approximated to the walls of the bony cavity and over this the gauze dressing is applied, so that the gauze is kept away from direct contact with the bone, and thus the pain consequent to its removal is obviated. In the performance of the radical operation, the facial nerve and external semicircular canal assume a serious im- portance on account of their position in the midst of the oper- ative field and the consequent danger to which they are invariably exposed. It is therefore desired, in addition to what has previously been said, to further add here a few more facts throwing light upon the dangers which exist and their avoidance in operations upon this region. In the re- moval of large masses of bone, the facial nerve is especially liable to be wounded during its course through the cavum tympani when the osseous tissue is being taken away to ex- pose the inner wall, the danger of traumatism at this point not being of any moment until a communication has been made with the tympanic space. After the opening in the mastoid has been made and the posterior canal wall is to be removed, the protector or a probe bent at right angles should be passed through the external auditory canal and held by an assistant in the posterior part of the epitympanic space, when the osseous tissue should be carefully removed, as previously outlined, until the protector becomes visible. In this way one has a guide to the exact location of the nerve, but as a still further protection, only the portion of the pos- terior wall directly in front of the mastoid opening should at first be cut away, and if this be done so that the opening thus made leads directly into the tympanum by the gradual removal of the bony wall there will be practically no danger of wounding the nerve by this procedure, especially if the compact bone mass forming the inner extremity of this wall is not interfered with to any extent. Jones, in thirty cases, EXPLANATORY NOTE TO PLATE XXXII. This plate shows the completed Stacke-Schwartze operation, with an exposure of the sigmoid sinus and the dura of the middle cerebral fossa. i, Sigmoid sinus; 2, middle cerebral fossa. 316 PLATE XXXII The Radical Mastoid Operation. 317 had permanent facial paralysis following in two and it was also transient in the same number, while he states that in order to avoid injuring the nerve, the operator must see well into the cavity in the bone. It may also be noted in this connection, that the development of facial paralysis after operation is not always necessarily due to injury of the nerve, as in a case reported by Mahn, the paralysis occurred a few hours after operation ; the patient, however, was subsequently accidentally killed and the autopsy showed that the paralysis was the result of an independent neuritis, as the nerve pre- sented neither a solution of its continuity, nor an apparent wound. If it be possible only to remove the lateral walls of the antrum, the nerve will rarely be injured here and the same avoidance of injury may be obtained by cutting away the posterior canal wall no lower than the middle of the margin of the tympanum. It should also be remembered that too tight packing may injure the nerve, and that this may also take place as the result of carelessness in using the protector, especially if any weight be exercised on its handle. In removing the post-meatal wall which is the most dan- gerous part of the radical operation as regards the Fallopian canal, Schwartze says that the blows of the mallet on the chisel should be careful and gentle, and not at a right angle but at an acute angle to the posterior wall, and the chisel should cut instead of prying out pieces of bone, while the beveled edge of the chisel should be so turned that its ten- dency would be to get shallower, rather than deeper. At the same time, as a matter of great importance, the bent or olive-pointed probe should be used at frequent intervals to carefully explore the parts which are being chiseled away. As a still further source of injury to the nerve may be the curette, for if this be used too forcibly or roughly, especially at the bend of the aditus or along the floor here, it may pene- trate too deeply an area of carious bone and seriously damage 318 Suppuration of the Middle Ear. the nerve; this can readily be avoided, however, by the em- ployment of gentleness and care in the use of this instrument and the free exposure of the operative field. What has been stated in regard to the facial nerve here is also equally applicable to the external semicircular canal, but with care this organ may readily be avoided, as it is situated immediately above the Fallopian canal and the open- ing in the bone must be unnecessarily high to injure it, and as a rule it can readily be recognized on the red coloration of the antral wall as a yellowish prominence. The exposure of the meninges or lateral sinus (see plate XXXII) during the course of an operation for chronic otorrhcea has been fully described in a previous chapter, but it may be further noted, that when the former is accidentally exposed one should avoid as far as possible the further employment of the curette or chisel in that particular place, for fear that the purulent secretion may drain between the dura and the adja- cent temporal bone and the area exposed should also be packed off from the general cavity in the bone by a separate piece of gauze, so that the possibilities of infection are more effectually guarded against. The same should be done when the lateral sinus is involuntarily opened, but if the hemor- rhage be profuse, it may become necessary to tightly pack the bone cavity with iodoform gauze and postpone the termi- nation of the operation to a later date until the walls of the sinus have healed. When a well-defined cholesteatoma is found on operation, or there is an excessive amount of cholesteatomatous tissue distributed through the cellular system of the bone, it will be necessary to somewhat modify the radical operation, espe- cially as regards the handling of the walls of the osseous cavity. Should the membrane which lines the cavity con- taining the cholesteatomatous mass be thoroughly cleansed of this material, no recurrence should take place, but expe- The Radical Mastoid Operation. 319 rience has shown that it is practically impossible to achieve this end and leave the membrane in place, as recurrence of the peculiar epithelial proliferation results within a compara- tively short time. Although Grant believes that when the radical operation for cholesteatorna is done, and a large cavity is found lined with a homogeneous membrane, one may leave the membrane in situ and simply scrape out the contents and sterilize the lining with alcohol. In several cases he found that this procedure was followed by speedy subsidence of the discharge and satisfactory after results. In some cases, and probably the majority in which this mem- brane appears to be smooth, it will be found on close exami- nation that it is pierced with numerous minute openings which communicate with small channels in the bone which are filled with the proliferating epithelium, so that it can be readily understood that irrespective as to how thoroughly the lining membrane itself may be removed, these channels in the bone cannot be obliterated by simple measures, so that in addition to the absolute removal of this membrane, it is also essential that the layer of osseous tissue beneath this, which contains the epithelial elements, must also be destroyed. Stacke, in order to accomplish this, after removing every- thing that presents the least evidence of pathological change, grinds down the bone with the electromotor burr, so that the epithelial masses in the Haversian canal system are oblit- erated, while for the same purpose, the procedure recom- mended by Zaufal may be satisfactorily employed of thor- oughly curetting the bone surfaces and then following this by the application of Paquelin's cautery, or painting the osseous walls with tincture of cantharides. Unless the pro- liferative power of the cholesteatorna membrane is entirely prevented by some of the measures here recommended, it will be difficult to obtain a healthy granulation surface for the bone cavity, and what is still more important, any por- 320 Suppuration of the Middle Ear. tion of it which may still remain acts as a matrix for the production of a further recurrence. Should these measures then fail to prevent its redevelopment, the osseous cavity should be carefully watched during the after treatment and every trace of excessive epithelial development should be radically eradicated with the curette. In those cases where this tissue has been so thoroughly removed at the time of the radical operation that recurrence need not be considered, the post-auricular opening, as will be described later, may be allowed to close by granulation, but where there is any uncer- tainty in regard to its recurrence, a permanent opening should be maintained posteriorly, so that the least evidence of recurrence may be seen and immediately eradicated. As in the simple mastoid opening, the electromotor burr has been employed to some extent in evacuating the bone in the radical operation, while as an aid in reducing irregu- larities of the walls of the osseous cavity, smoothing off pro- jecting bone surfaces, and especially in grinding down the bony walls when cholesteatoma has been removed, it is of great value. Experience has shown to a great extent that it is not advisable to employ the burr in the tympanum, but elsewhere its employment is comparatively safe, and it is especially advantageous in leveling down the facial spur, as the slightest irritation of the nerve becomes immediately evident, so that the facial muscles at once contract, and with a minimum amount of precaution, severe injury to the nerve is very improbable. Barkan believes that the mallet and chisel will ultimately be given up for the burr in performing the mastoid operation, and as being superior to the former for this purpose, he states that when we come down too near the extremity of the bony wedge, where the Fallopian canal and horizontal semicircular canal lie in close proximity, he found that the insertion of an ordinary strabismus hook be- tween the bony wedge and the neighboring wall of the tym- The Radical Mastoid Operation. 321 panic cavity affords a perfect protection against accidental injury of either the facial or semicircular canals, the hook being pressed forward and the burr being made to work against it. In the use of the burr in the bone cavity, either for removing large masses of carious bone or reducing irreg- ularities, care should be taken that from time to time it be allowed to cool, for if this is not done the heat generated in destroying the osseous tissue may be sufficient to produce considerable damage, as in several recorded cases its employ- ment has resulted in necrosis of the walls of the osseous cavity from the reduction of the vitality of the tissue by the excessive heat generated in its rapid rotation. 22 CHAPTER V. MODIFICATIONS OF MASTOID OPERATIONS. 323 MODIFICATIONS OF MASTOID OPERATIONS. The radical mastoid operation, when performed to re- move the morbid tissue causing the discharge and associated symptoms in chronic suppurative otitis media, is of necessity modified to some extent in adaptation to the particular fea- tures present in almost every case, but whether any step of the operative procedure deviates from the methods usually employed, the principle aimed at must always remain the same, the object of the various methods employed being to convert the antrum, epitympanic space and tympanum proper into one open single cavity instead of a series of partially closed ones, and to also bring these into direct relation and as a part of the external auditory canal or the eviscerated mastoid process. The finished procedure, as far as the cut- ting away of the osseous tissue is concerned, more nearly approaches the surgical ideal, being the one in which all the diseased tissue is removed without damage to the highly important structures in relation with the affected parts and these latter cavities being thrown into a single space with smooth healthy walls. When the suppurative middle ear disease has been 325 326 Suppuration of the Middle Ear. neglected and a fistula of the mastoid process has developed, either at its most common site on the cortex near the center, or above, in close relation with the opening of the meatus, modifications in the operative procedure may be necessary, as stated by Politzer, as the fistula usually leads into a large cavity filled with pus and granulation tissue, or often with cholesteatomata and sequestrated fragments of bone. In such cases the initial incision should be made over the fistula, and it is often only necessary to chisel away a thin bony shell to expose the middle ear, as the postero-superior wall of the canal and part of the external attic wall are generally de- stroyed. When this condition is found all that is usually required is to remove the granulations and cholesteatoma- tous masses, the remains of the osseous meatal wall and attic, with the projecting bony ridges, and scrape out and smooth off the walls of the cavity. In very rare instances the sclerotic changes of the mas- toid process may be so great that it is impossible to perform the Stacke-Schwartze or any operation which contemplates opening the antrum through the mastoid on account of the excessive projection forward of the lateral sinus. This abnormality has been previously mentioned, but when it is found to be present, even a large cavity in the bone cannot be made with the ordinary Stacke method and it becomes necessary to continuously chisel the bone away by means of a very small chisel through the external auditory canal into the attic and aditus, as it will be found in such cases that but little remains of the antrum as it has become greatly reduced in size. Fortunately, in such individuals the amount of carious bone is very small and nearly always limited to the immediate region of the cavum tympani, so that in cutting the bone away in a backward direction to reach the antrum, which should be found and opened, however small it may be, one is not necessarily exposing the patient to great Modifications of Mastoid Operations. 327 danger, especially if the protector is passed through the ex- ternal canal and is used as a guide in the ordinary manner after the epitympanic space has been freely laid open. Jackson has pointed out that the hearing power has been much better where the posterior wound has been allowed to heal from the bottom with the removal of the posterior canal wall in the usual manner, but not incising the membraneous canal and thus avoiding the resultant deformity of the concha, sometimes necessary to obtain an adequate meatal opening of sufficient size for the after treatment, as made in the usual Stacke-Schwartze operation, with the Koerner or Panse flaps. Where both ears are affected and the ques- tion of audition assumes a much more serious aspect, he advises against these operative procedures and favors the healing of the posterior wound from the bottom whenever possible, on account of this method more safely conserving the hearing. In the operation upon the single ear, which is usually the case, and where the hearing in the other ear is normal or of fair efficiency, one should be careful in trans- planting skin to cover the bone defect that it is not placed too thickly over the region of the oval or round windows on account of the impairment of hearing which may some- times ensue. In epidermic transplantation to overcome cho- lesteatomatous formation, Bezold claims that when this is used in the bone cavities it reduced the period of healing to weeks instead of months, as the skin flaps thus trans- planted line the previously suppurating cavities with a dry membrane instead of a moist secreting surface, and the necessity of a permanent opening behind the auricle is abol- ished. It must be remembered, however, that credible ob- servers have found that the epithelial proliferation may occur in the skin in which the aural cavities have been lined, so that under all conditions this in itself is not an absolute guar- antee that the cholesteatoma will be permanently inhibited. 328 Suppuration of the Middle Ear. As regards the method of removing the osseous tissue in performing the radical operation for chronic tympanic sup- puration, the Zaufal method is often compared with that of the Stacke-Schwartze, and for all practical purposes as regards its technique is similar to it, these two terms being used quite often interchangeably in describing the radical operation. Zaufal, however, removes the mastoid cortex and the postero-superior wall of the osseous auditory canal and then enters the antrum, after which the external attic wall is removed and the epitympanic space exposed. The similarity between this and the usual radical operation is therefore very close, the modification only consisting in the removal of the postero-superior wall of the canal at the same time as the mastoid cortex is cut away, instead of directly entering the antrum at first through the mastoid process and then as a later step cutting away the canal wall, the technique of the operation in both instances being otherwise the same, and as it has previously been described, will require no further repetition here. The Zauf al-Kuster method of opening the antrum through the mastoid process as the primary procedure differs in no essential from the method here described, excepting that a mastoid bone flap may be formed to close the posterior open- ing as in the Kuster operation, which will later be mentioned. The Panse modification, when employed in the presence of cholesteatoma, does not concern the removal of the osseous tissue in any way differing from the complete radical opera- tion, but is essentially concerned in the method of making the flaps for lining the exposed bony cavities from the mem- braneous canal, which will be described in detail in the suc- ceeding chapter, the object of this flap method being such that through the large meatal opening the bony cavity can be thoroughly examined in every part and the presence of any redevelopment of the cholesteatoma may be immediately determined and properly treated. Modifications of Mastoid Operations. 329 Biehl, in order to save as far as possible the tympanic contents, in cases of radical operation where the suppura- tion is confined to a greater or lesser extent to the attic, with the presence of a perforation in Shrapnell's membrane, as a first step of his operation opens the aditus by removing its lateral wall. After this has been done and the extent of the diseased process has been ascertained, the usual radical operation may be carried out if the condition of the parts warrants it, or in the cases, as here described, in which this modification is applicable, all or part of the outer wall of the attic or antrum, or both, may be removed as required in the particular case, the value of this procedure being mainly in the fact that it protects the facial nerve from any damage and allows of the complete exploration of the attic in front and of the antrum behind, and thus decides how far operation on these parts may be necessary. As in a not inconsiderable number of cases it is not absolutely necessary to remove the membrana tympani and ossicular chain by this method, it is sometimes possible, as claimed by its author, to remove the purulent nidus from the aditus and antrum, and the attic and ossicles are thus restored to their normal condition as far as the presence of suppuration may be concerned. The modification of the radical operation of whatever nature, in which the diseased tissue is removed by enlarging the external auditory canal from within the canal backwards instead of from the mastoid process forwards, irrespective of the particular method employed to accomplish this, to a great extent in many cases possesses considerable advan- tage over what has been called the double channel operation, inasmuch as the after treatment is carried on through two openings, one being the meatus, the other the posterior open- ing in the soft tissues and bone. The single channel opera- tion, when such is practicable, obviates this, and as shown 330 Suppuration of the Middle Ear. by Love, the former possesses certain disadvantages, as the patient must wear an external dressing for a number of months to cover the mastoid wound ; when it is determined to close this wound there is great doubt as to the conduct of the inner end of the mastoid cavity as to whether it will become an undrained sinus or pocket in which pus will collect and produce considerable trouble in the future, thus defeating the object for which the operation was performed, as it is cer- tain in quite a number of cases that the purulent discharge continues even after the most careful treatment. Although healing does take place after a longer or shorter period, there is often an unsightly depression remaining behind the auricle, while the surest result is obtained by keeping the mastoid wound perfectly open until all discharge from the middle ear has ceased and to then close it by a plastic opera- tion. In contradistinction to these disadvantages of the double channel operation, the single channel method, as shown by this author, offers the advantages that all dressings may be removed from the side of the head within two weeks and the patient may again resume his usual occupation at that time. All the after treatment is carried out by way of the widened canal, which should be so large that every part of the healing surface can be seen through the speculum and every nook or corner of the space can be thoroughly cleansed and treated as may be indicated, while another great advan- tage is that complete healing takes place as a rule by the third month after operation. Gelle's modification of the mastoid operation concerns itself only with the avoidance of danger to the facial nerve and the horizontal semicircular canal, by cutting away the osseous tissue in their neighborhood by means of a specially constructed saw instead of the usual method of the chisel. The usual opening of the antrum is first performed through the mastoid process, and after the antrum has been fully Modifications of Mastoid Operations. 331 exposed, a wire is introduced through this cavity forwards into the tympanum and out through the external auditory canal. This wire is employed only to carry the saw to its position within the cavities and when it has been placed in situ the remaining bridge of bone is cut away by it. A chain saw is used, the links being very short, so that the instrument may readily be drawn from the antrum through the exposed tympanic cavity and two cuts are made by it; the first from above downwards, which should be directed towards the apex, while the second incision is to be made in a horizontal direction, so that in this way the bony wall is removed by cutting away the deeper parts from within outwards, while, as the cuts are made external to and below the parts which it is necessary to avoid, no danger can occur in this particular region. Bergmann's operation, which is one of the most impor- tant modifications of the radical procedure, is characterized by the removal of the inferior lamella of the superior wall of the external osseous auditory canal and in connection with the external attic wall this part is cut away before the re- moval of the posterior osseous canal wall, which is later destroyed and the antrum then opened. This operation is especially indicated in those cases of chronic suppuration where the attic and pneumatic spaces of the mastoid process bear the brunt of the morbid changes and in which drainage by way of the lower tympanum and canal is not sufficient-, the removal of the carious bone with the granulation tissue and purulent material being thoroughly accomplished by this procedure. The basis of this operation depends upon the anatomical development of the squamous portion of the temporal bone in relation with the cavum tympani, as the bone here is divided into two well-defined lamellae, of which the internal comprises a part of the roof of the tympanic cavity, while the second lamella closes the opening between 332 Suppuration of the Middle Ear. the extremities of the tympanic ring in an inward and down- ward direction, so that when fully developed the ring is closed by this curved segment in this manner. As the growth of the squamous plate continues during early life, it so pro- jects that the roof of the external canal, of which it forms a part, extends externally in a plane that is nearly horizontal, so that in the young child, where it forms an arch-like struc- ture at this point, becomes changed in later adult life, and here forms the horizontal osseous lamella spoken of. As shown by Bergmann, the outer attic wall is placed at an angle formed by the divergence of these internal and external plates of the squamous process, and if an opening be made parallel to the roof of the canal between these two osseous plates, it will enter the epitympanic space. To accomplish this the usual incision is made over the mastoid close to the insertion of the auricle and the membraneous canal is sepa- rated from the osseous canal walls as before described, so that the superior margin of the bony canal is thoroughly ex- posed. The upper wall of the canal and the osseous tissue beneath it, which is mainly diploic in character, is then cut away with the chisel until the epitympanic space has been exposed, the lines of the bone removed following the superior wall of the canal in an inward direction. As this part of the tympanum contains the articulation of the malleus and incus and is by far the most frequent seat of pathological change, especially of a carious process, it is thus directly exposed by the removal of the osseous tissue in this manner. The ossicles or their remains are thus extracted through this opening in the bone and the tegmen tympani is curetted and carefully exposed for carious bone which should be removed if found here, while should the extent of the pathological process be such that the antrum and mastoid cells are then found to be involved, they may be readily opened and cleaned out by enlarging the opening already made in the bone in Modifications of Mastoid Operations. 333 a posterior direction. After all the diseased tissue has thus been eliminated, the postero-superior wall of the mem- braneous canal may be then divided and the soft tissue flaps thus obtained are pressed backwards over the bony cavity which has been formed, so that the entire system of cavities and cell spaces of the region are thrown into one common cavity in relation with the tympanic space and the parts can then be treated by way of the enlarged external canal, or any carious areas which may subsequently develop can be eliminated in this manner instead of reopening the mastoid process, as in some other forms of operative procedure. As a method of removing carious tissue and obtaining free drainage from the deeper portions of the involved temporal bone, this procedure, either alone, or preferably in connec- tion with Stacke's operation, possesses many features of value, especially in those cases where for various reasons it is considered inadvisable to enter the antrum through the mastoid process, while in the small class of cases where the lateral sinus is placed so far anteriorly that the antrum can- not be entered except by way of the canal, it may be employed with considerable satisfaction, the gauze drainage and ex- ternal dressings being the same in this operation as in the usual Stacke procedure and the after treatment is also carried out along the same lines. The Ballance operation for chronic suppurative otitis, is, according to Gibson, the most radical of all complete mastoid operations, but it is attended with less disfigurement and is followed by quicker healing of the bone cavity than any other operation of so radical a nature, the chief features of this operation being that the skin incision, though quite long, is in the line of the hair and becomes practically invis- ible after the complete healing of the parts, the mouth of the meatus is enlarged without disfigurement, while the pos- terior wall of the cartilaginous meatus with the posterior 334 Suppuration of the Middle Ear. wall of the concha is displaced upwards and backwards and so fixed as to form the outer and part of the superior wall of the posterior portion of the enlarged meatus. Gibson further stating as an important modification, that in from ten to twenty-one days after this portion of the operation the essential parts of the granulating walls of the enlarged bone cavity are covered with Thiersch grafts which, if suc- cessful, lead to the rapid healing of the whole cavity and its being lined by a thin layer of epithelium. Ballance states that in order to obtain a successful outcome of a mastoid operation it is requisite to obtain the fulfilment of two con- ditions, the complete removal of all diseased tissue, and sec- ondly, the healing of the large bone wound which this neces- sitates from the bottom. In order to avoid the pain conse- quent upon the frequent tamponing of the cavity and to shorten the long time before cicatrization is complete in the usual radical operation and to ensure the thoroughness of the epidermization of the bone cavity, he modifies the opera- tion by carrying out two separate procedures, the first being the operation for the removal of all the diseased tissue, and the second procedure which follows at a later period the operation for healing the wound. In performing the first of these two operations, the usual incision is made behind the auricle which is held well forward with the retrac- tor. The bone opening is then made with the electromotor burr or gouge and the posterior wall of the bony meatus is removed with rongeur forceps; the entire outer wall of the attic should also be removed, so that the external auditory canal, tympanum, attic, antrum and as much of the mastoid as is necessary is converted into one large bone cavity. The operation should be done under brilliant illumination and all parts should be thoroughly curetted with sharp spoons until the osseous walls of the cavity are left clean and hard, care being taken in curetting the posterior part of the inner wall Modifications of Mastoid Operations. 335 of the tympanum on account of the danger to the overhang- ing Fallopian canal here, as the fossa of the aqueduct fre- quently contains granulations and may be carious, while in removing the bone the Stacke protector should be employed to shield the facial nerve and external semicircular canal as in the usual operation. An incision is then made into the inferior wall of the cartilaginous canal, throughout its entire length and carried well into the concha, where it is pro- longed with a curve upwards and backwards as far as the level of the anterior commencement of the helix. The thick layer of tissue behind the meatus is then removed and its posterior wall forming this part of the meatal flap is pushed upwards and backwards and attached to the mastoid flap by silkworm gut sutures. The osseous cavity is then thoroughly cleansed and packed with narrow strips of gauze, of which the end should be brought out through the meatus, while the incision over the mastoid process should be completely closed with fine silkworm gut or horse hair sutures. If there is much discharge from the ear, the packing in the bone cavity may have to be changed within a few days, but if the cavity has been thoroughly cleansed it can usually remain un- changed until the time for the second operation. The second step of the operation consists in the appli- cation of skin grafts to the osseous cavity when it has become lined with delicate pink granulation tissue, which usually takes place in from seven to ten days, but may take from two to three weeks. The patient is anaesthetized, the original incision over the mastoid process is opened with the handle of the knife and the auricle is displaced well forwards. All oozing or active bleeding from the edges of the wound or granulating surface is then controlled after the gauze pack- ing has been removed and large epithelial grafts taken from the thigh or arm, or preferably a single graft is made to cover and lie flat against every part of the walls of the 336 Suppuration of the Middle Ear. cavity if such be possible. In applying the graft it is essen- tial that the following parts be thoroughly protected by it: the anterior wall of the cavity formed internally by the ante- rior boundary of the tympanum and attic and externally by the anterior wall of the large osseous meatus, the anterior part of the cavity formed by the tegmen tympani and the superior wall of the enlarged osseous meatus, the inner wall of the attic and tympanum, the roof of the antrum, the ridge formed by the facial canal, and the inner wall of the antrum. If more than one graft is used, care should be taken to avoid overlapping on the one hand and the leaving of uncovered granulation tissue on the other, while drops of blood or bubbles of air caught between the graft and the bony wall should be avoided as much as possible, as they are apt to produce considerable trouble. This is best overcome by placing the graft edgewise over the depth of the cavity in- stead of pushing it directly by its central portion into the tympanum. Tiny moist pledgets of gauze and steel probes with pear-shaped heads measuring from four to six milli- meters in diameter are used in accurately applying the graft to the raw bone surface, so that when the grafting is com- pleted all eminences and depressions should be as clear to the eye of the operator as before the operation. The best protective for the grafts is pure gold leaf about one or two one-thousandths of an inch in thickness, which is carefully pushed into position so that all eminences and depressions in the bone are clearly denned. After this has been carefully placed, a narrow strip of dry iodoform gauze is packed into the tympanum, attic and antrum and the end is brought out through the meatus. The mastoid incision is then com- pletely closed and the usual outside dressings are applied. One week later the packing is removed, which procedure is absolutely painless, but the gold leaf is allowed to remain for a longer period. Three or four days later this should Modifications of Mastoid Operations. 337 be gently removed with forceps after irrigation and the irreg- ular cavity will be seen to be pure white in color, when a small amount of dry gauze is packed against the grafts and this is changed every two or three days until healing is com- plete. Milligan advises as an improvement in this proced- ure, in order to avoid the constant oozing at the grafting operation, that the original incision over the mastoid be opened two days previous to placing the grafts, while he also suggests in order to avoid some of the difficulties in manipu- lating the grafts that they be floated into position by filling the cavity with a warm saline solution, which may afterwards be withdrawn by means of a pipette. While for some time previous to the publication of Kuster's original method of entering the tympanum, the removal of the posterior wall of the osseous external canal had been recommended, this operator at a later period more clearly defined the necessity for such a procedure in certain cases of chronic suppurative otitis media. He carries the opening directly into the tympanum and this cavity with the antrum is curetted as may be required, the main object of this operation being to thus remove the posterior wall of the canal in order to expose the middle ear cavities, and he bases the rationale of this procedure upon the general surgical principle that when a collection of pus is confined within a bony cavity, the focus of infection should be freely opened in order that the morbid changes present can be seen and the pathological tissue thoroughly eradicated. Kuster's more recent modification of the radical operation concerns itself directly with the method of opening the mastoid process and is known as the osteo-plastic method. The method of forming the osteo-plastic flap consists in drawing the auricle well forward and making an incision close along its posterior attachment, beginning slightly above the level of the external opening of the auditory canal. The incision is then carried 23 338 Suppuration of the Middle Ear. downward around the tip of the mastoid process and is then continued upward along its posterior border to the same level as its beginning. This forms a U-shaped incision which should be made through the periosteum to the bone, the periosteal layer and soft tissues then being pushed aside with the elevator and with a broad chisel a shallow groove is cut into the bone following the entire outline of the usual incis- ion. Beginning at the bottom of this channel in the bone, a thin osseous flap or plate is then split off, which is adherent to the soft tissues and the entire skin-periosteum-bone flap is turned upwards, leaving the field of operation free. After the diseased tissue of the mastoid and the cells in con- nection with it have been removed in the usual manner, the flap in its entirety is replaced, but in order to accomplish this in a satisfactory manner it may be necessary to cut off a small piece of the bone from its lower end, so that a small drain may be led from the cavity formed inside the bone to the surface. The author claims for this method that it presents little difficulty in its performance, rapid healing takes place, and in case the sinus or dura have been injured, it affords a good opportunity to apply the tampon. Experience has shown, however, that such is not the case, and as has been noted by other observers, his claim in regard to the flap being of advantage in injuries of the meninges or lateral sinus is not worthy of consideration, while the method offers no advantages at all over the usual operations, but possesses a rather doubtful value. Relative to the making of the skin flaps, various modi- fications have been devised by different operators, some of more or less value, while others are of less importance, and are only applicable in a limited number of cases. Of the modifications which have proven of service in some cases, Lake proposes in Stackers operation to pave the floor of the artificial opening between the external ear and the antrum Modifications of Mastoid Operations. 339 with the dermal lining of the external auditory canal only, the cartilage being dissected off at the time of the operation. While the same author, after the radical operation, believes that the posterior meatal flap should be entirely removed, because after it has been turned back to line the roof of the large cavity made in the osseous structures, the ceruminous glands in the flap continue to functionate and the cerumen which is thus produced is unable to escape and acts as a for- eign body, causing considerable annoyance. In such cases where the ceruminous glands are very prominent over this portion of the canal wall, it will be advisable to remove the tissue, as advised by Lake. Dench recommends a method of forming these flaps from the canal wall by continuing the usual horizontal incision along the posterior medial wall of the cartilaginous canal, outwards to about the middle of the concha and from the conchal extremity of the horizontal incision, another incision is made in a vertical direction upwards and another in the same manner downwards. By dividing the tissues in this way, two quadrilateral flaps are formed and then the conchal cartilage in each flap is dissected out and the tissues are folded backwards upon themselves, so that the lower flap is drawn downwards, while the other flap is placed upwards, and both are stitched into position with fine gut sutures, so that the opposing raw surfaces are brought into apposition. If it is seen that these sutures are not sufficient, it may be necessary in some cases to place deep retention sutures of stronger gut. A better method of forming the flaps described by the same operator, is to incise the meatus in the direc- tion of its long diameter along the line of its posterior aspect well out into the concha. From the point where it enters the concha, the incision is curved upwards parallel to the antihelix and a short distance in front of this point to immediately below the anterior crus of the antihelix. In 340 Suppuration of the Middle Ear. this manner a large flap is formed, consisting of the posterior and upper walls of the fibrous auditory meatus and a tongue- shaped conchal flap. The dermal layer of the concha is raised up and dissected off from the cartilage of the flap and the cartilage is grasped with forceps, dissected away from its posterior attachments and excised. The meatal flap is then turned backwards upon itself and stitched in position with interrupted sutures of fine catgut, while the tongue- shaped flap is turned backwards and upwards through the large meatal opening formed by the cutting away of this flap and is stitched in position to the raw surface posterior to it by fine catgut sutures. Randall, in performing the radical operation, advises the omission of a permanent opening behind the ear as being the only positive cure for the chronic suppuration, and he further believes that the mastoid cells are not to be included in the operative removal of the parts unless they are demon- strably affected. He obtains epidermization of the cavity, which has been cleansed out, without even a temporary retro- auricular opening and the mastoid wound is healed by first intention after it has been closed with silver wire sutures. In making the skin flaps, the posterior flap from the fibrous canal is split into two layers, one being composed of skin, the other of periosteum; the cartilage is then removed, so that a large pliable flap is obtained which readily adopts itself to the purpose for which it is designed. The flaps are held in place by means of gauze pledgets through the meatus, but they are also fastened originally in position through the wound behind the auricle, after which the latter is perma- nently closed and the subsequent dressings and after treat- ment are carried out through the external auditory meatus. As a method of filling in the opening behind the ear after the radical operation for chronic suppurative otitis media, the procedure adopted by Waring may be useful in a few Modifications of Mastoid Operations. 341 cases. He makes a free opening in the mastoid and after thoroughly curetting, fills the entire space with long, thin strips of cartilage and bone taken from the femur and tibia of a young kitten, which is killed during the course of the mastoid operation. The posterior wound is then closed with sutures and the external auditory canal is packed with a strip of gauze. In one case of cholesteatoma in which this pro- cedure was carried out there was no indication of its return after two years, while in another case, where the large cavity was irrigated for several weeks, rendered sterile and then filled with the cartilage and bone strips, cure resulted and the cavity became completely filled, and in another case, owing to the difficulty in making the cavity aseptic, the bone grafts did not take and the Ballance grafting operation was then successfully performed. CHAPTER VI. THE RETRO-AURICULAR OPENING AND PLASTIC METHODS. 343 THE RETRO-AURICULAR OPENING AND PLASTIC METHODS. While various modifications of the usual methods of making flaps from the membraneous canal walls in order to cover the exposed bone surfaces and hasten epidermization after the radical operation for chronic suppurative otitis me- dia have been discussed in the previous chapters, it is desired here to more thoroughly take these methods into considera- tion, especially in relation to the permanent retro-auricular opening and to describe the methods that are usually em- ployed for this purpose. Two main objects are to be attained by the employment of plastic flap methods after the osseous tissue of this region has been extensively removed for chronic tympanic suppuration, the first being to obtain a complete epidermic covering for the walls of the cavity, as from the epithelium of the surface of the flap, proliferation takes place, and if the underlying granulating surfaces be healthy, they become covered with a dry, nonsecreting layer of protecting epithelial tissue. While the second object which is equally important as regards drainage and the hearing ability of the individual, is the prevention of stenosis or actual stricture of the canal from the inflammatory thickening or subsequent 345 346 Suppuration of the Middle Ear. contraction which takes place at the point where the mem- braneous tube has been necessarily divided in performing the radical operation. After the removal of all the diseased tissue, the ultimate cessation of the purulent discharge is dependent upon the complete epidermization of the cavity surgically made in the bone, and in order to accomplish this desirable and neces- sary issue, the essential epithelial cells must be obtained from the anterior and inferior canal walls which have been allowed to remain in their natural position, from the flaps made from a portion of the membraneous canal, and if this is not suffi- cient, from transplantation by means of Thiersch grafts. In the first instance, the epithelium commences to grow from the canal into the tympanum, as described in the epidermi- zation of the cavum tympani after operation via the external auditory canal, but the time required for the epithelium thus produced to cover the walls of a somewhat extensive cavity it so indefinite that even when the plastic flaps are also em- ployed, skin grafting may be used, especially in the deeper parts of the tympanic cavity and antrum which the flaps will not cover, to diminish the time necessary for epidermization and increase the rapidity of the healing process, the grafts being applied in the manner previously described, either at the time of operation or at a later period when the osseous surfaces have become covered with a layer of granulation tissue. One frequently finds from time to time minute areas of epithelial development on the inner walls of the cavity, completely isolated from similar groups of cells; these are produced from small patches of mucous membrane left after curetting, and in time they take on the characteristics of a nonsecreting cicatricial membrane. As a rule, however, such islets of tissue are of but little value in effecting the desired epithelial transformation, although they are undoubtedly of service in aiding the growth of the transplanted epithelium Retro-Auricular Opening and Plastic Methods. 347 which may be applied in their vicinity. Should the latter fail to "take," one should look for evidences of defective aseptic precautions or the presence of further carious changes in the osseous walls, but in a certain small proportion of cases, where the grafting has been carefully performed and where the condition of the parts is healthy, the grafts, after grow- ing for a time, cease to remain in normal condition and become destroyed or devitalized to a greater or lesser extent. The choice of the method to be employed in making the flaps from the membraneous canal varies to a great extent with the amount of osseous tissue to be covered in the indi- vidual case, the desires of the operator, and the post-aural conditions, some methods being inapplicable when the in- cision over the mastoid process is closed at once to obtain healing by first intention, others being of service only when the post-auricular opening is to remain permanently, or when it is to be allowed to close by granulation tissue at an earlier or later period. The method of Panse ( see plate XXVII ) is most suitable in cases where the posterior opening is to be main- tained for some time or where it is to be kept permanently open, as it gives ready access to the entire cavity in the bone, and by using this method the meatal opening may be made as large as desired, as any moderate deformity which may be thus produced is to a great extent hidden by the antitragus. While it is of especial value in those cases where on account of the extensive area involved by the diseased process, one can not be perfectly sure that all the carious bone has been removed, as this procedure covers only the edges of the osseous cavity and any further caries which may recur under such circumstances may be readily thrown off or seen and properly treated. To make the flaps as recommended by this operator, a pair of forceps are passed into the external mem- braneous canal throughout its entire length, so that one por- tion of the instrument is within the membraneous, the other 348 Suppuration of the Middle Ear. on the outside of this tube, and with a blunt knife the canal is divided parallel with its walls along the entire length of its posterior wall to the posterior edge of the external meatus. This incision is as long as necessary to make a fair-sized meatal opening if the bone cavity be not too large, but if a large amount of osseous tissue has been removed from the mastoid process the opening will not be sufficient, and then one must lengthen the incision in the posterior wall of the canal, so that it extends somewhat into the concha. At the termination of the external end of the incision, two shorter incisions are made at right angles to it, one being directed upwards, the other in a downward direction, so that two flaps are thus cut out of the tissues. As these flaps are somewhat rigid and immovable, they are now thinned down by cutting away a portion of the tissue on their posterior aspect with curved scissors and the inferior flap is then attached to the anterior portion of the osseous cavity, which is in intimate connection with its inferior border, by means of one or more gut sutures as may be necessary. The supe- rior flap is placed in position in the same manner against the upper wall of the tympanum and osseous canal and it may be held in place with sutures as used in the other flap. In those cases where it is desired from the onset to maintain a permanent retro-auricular opening, the epithelial surfaces of both flaps should be brought into immediate contact with the skin surface of the incision over the mastoid process and there retained by sutures, but this procedure should not be adopted when it is desired to close the mastoid wound by granulation, as under such circumstances a definite area of exposed tissue should be allowed to intervene between the flaps and the skin surface of the posterior opening. In the Koerner plastic operation (see plates XXXIII and XXXIV) the mastoid incision is closed at once, so that healing by primary intention may be obtained, and as EXPLANATORY NOTE TO PLATE XXXIII. This plate shows the Koerner flap operation. 1, The first incision along the upper border of membrane-cartilaginous auditory canal. 2. Dotted line indicating the lower second incision. 35 PLATE XXXIII EXPLANATORY NOTE TO PLATE XXXIV. This plate shows the completed Koerner flap operation with the flap retracted and ready to be placed in position. i, Forceps holding the thinned flap made from the posterior membrano-carti- laginous canal wall. 352 PLATE XXXIV Retro- Auricular Opening and Plastic Methods. 353 it produces four areas from which epidermization can take place, it affords a rapid method as compared with some other plastic procedures, of healing the suppurating cavity in those cases where the operator entertains no doubt but that all the carious bone has been eradicated when the flaps are placed. Should this method be employed and any diseased tissue be allowed to remain, the flap over such an area is very certain to break down and this becomes espe- cially unfortunate in those cases where there is a tendency towards the contraction of the external meatus, although this can be overcome to some extent by the employment of a large drainage tube during the course of the after treatment. In this, as in other similar procedures, the size of the meatal opening depends to a great extent upon the extension of the incision outwards into the concha and to a lesser degree upon the tamponading of the parts. When there is some degree of absorption taking place, this opening may gradually increase in size, so that at a later period it becomes larger than at the time of operation and the inte- rior of the bone cavity can be readily seen in all its parts, while the facility of thus treating the parts is enhanced by the bending backwards of the cut cartilage of the auricle, which is an essential part of this method. To perform the Koerner plastic operation two clamps are employed in the following manner : the branch of one of the clamps is placed in the canal and the other, which has a long fenestration, is placed in such a position that it will be in contact with the posterior surface of the fibrous tube and holds the canal as far down inferiorly as possible. The second clamp is then applied above so as to fix the canal wall in this position, and with a pointed knife an incision is made the length of the opening in both the lower and upper clamps, when the instruments are then removed. In order to obtain flaps of the proper shape and size, the two parallel incisions should 24 354 Suppuration of the Middle Ear. be from a quarter to three-eighths of an inch apart from each other, and after the clamps have been removed, both incisions should be extended well out into the tissues of the concha. The flap thus formed is made more flexible and thinner by cutting away a portion of the tissue from its pos- terior aspect, as in the Panse flap, and it is turned back so that it accurately fits into the posterior surface of the osseous cavity. In order to place and retain the flap in the desired position, a large rubber drainage tube, which has been split for its entire length, is placed in the external canal with the cut portion looking towards the anterior wall and the flap is in contact with the posterior aspect of the tube. By push- ing this backwards the flap is held in position when the auricle is replaced and the tampons applied. In order that the flap retains its position and is not loosened when the gauze packing and drainage tube are later removed at the first dressing, the flap should be tamponed through the tube with small strips of iodoform gauze, so that both the rubber tube and the flap are firmly held against the posterior aspect of the osseous cavity. When the gauze packing has been completed in this manner, the mastoid incision is closed with sutures and the usual dressings are applied, the rubber drainage tube being allowed to remain in position until the flap is adherent to the bony walls, when it can then be taken away, this often being possible at the first dressing subse- quent to the operation. Politzer changes a part of this oper- tion to some extent, in order to lessen the irregular size of the external opening of the canal which results from the bending back of the cartilage of the concha, by making two short incisions in the cartilage of the auricle and the meatus, starting from the external extremities of the first incision. By modifying the procedure in this way the meatal opening of the canal is also somewhat enlarged in the same direction and for a similar purpose the latter operator excises a small piece of cartilage from the crus helicis. EXPLANATORY NOTE TO PLATE XXXV. This plate shows the position of the bistoury in making the first incision in the Jansen modification of the Stacke flap operation. 35 6 PLATE XXXV EXPLANATORY NOTE TO PLATE XXXVI. This plate shows a step in the Jansen-Stacke flap operation. The first incision having been completed, the ear is retracted and the cartilaginous canal is exposed in the field of the completed radical operation. 358 PLATE XXXVI EXPLANATORY NOTE TO PLATE XXXVII. This plate shows the second incision in the Jansen-Stacke flap operation. The scissors introduced along the dotted line indicating the longitudinal incision. The Panse flap consists in making an incision at equal distances from the upper and lower ends of the first (vertical) incision. A B, First incision ; C D, second incision ; E F, Panse method. 360 PLATE XXXVII EXPLANATORY NOTE TO PLATE XXXVIII. This plate shows the Jansen-Stacke flap operation completed, the flaps being placed in position. i, The small upper flap; 2, large lower flap. 362 PLATE XXXVIII Retro-Auricular Opening and Plastic Methods. 363 In addition to what has previously been pointed out in regard to the Stacke operation, it is here desired to briefly describe two plastic methods suggested by that operator. The first of these is made from the tissues of the mem- braneous auditory canal and consists of a single longitudinal incision made through the entire length of the superior wall of the canal as far outwards as the concha. Close to the concha and at right angles to this incision, a second incision in the tissues is made in a downward direction, so that a rec- tangular flap is formed, composed of the posterior and a part of the superior walls of the fibrous canal. This is then pressed against the inferior and posterior surfaces of the osseous cavity and is held in place by tampons of gauze in- serted through the enlarged auditory canal, while in those cases where it is necessary to maintain a permanent retro- auricular opening, the external angle of the canal flap is sutered to the inferior angle of the mastoid incision. Jansen modifies this procedure by reversing the order of the incis- ions (see plates XXXV, XXXVI, XXXVII and XXXVIII). The second plastic operation advised by Stacke is also em- ployed to line the mastoid cavity and is composed of both skin and periosteum, and unlike the former flap methods, the tissue is taken from over the mastoid surface instead of from the membraneous auditory canal. Previous to the performance of the radical operation on the osseous structures, a large tongue-shaped dermal flap is cut out from the mastoid sur- face by an incision including the skin and subcutaneous tissue. The flap thus produced has the apex directed down- wards, with its large base above over the temporal line. A tongue-shaped flap is then made from the periosteum of the mastoid region by two diverging incisions extending down- wards, so that the base of the reverse of the skin flap is placed at the insertion of the sterno-mastoid muscle and the apex at the temporal ridge. The superior flap, which is 364 Suppuration of the Middle Ear. composed of skin and subcutaneous tissue, is then placed in position over the roof of the tympanic cavity and antrum, while the second flap of periosteum is made to cover the floor of the antrum and as much as possible of the facial spur, the final step of this procedure being the transplanta- tion of skin grafts on the granulating surface of the perios- teal flap. Siebermann alters Stacke's canal flap operation by con- tinuing the original incision out into the concha in a Y-shape, so that three flaps are formed. In order to apply these flaps to the desired position, the small middle flap, which com- prises the cartilage of the concha is cut out and the parts are then maintained in position with gauze tampons. Sie- bermann's original plastic method is somewhat more difficult to perform than the usual flap operations and it is to be employed only in those cases where it is desired to form a persistent retro-auricular fistula. He first makes the usual Stacke flap and fastens the short edges of this to the lower angle of the mastoid wound, so that the meatal flap is at- tached to the anterior edge of the mastoid opening at its inferior part. The free edge of the concha is then protected by the dermal surface of both the anterior and posterior parts of the auricle and a movable flap is then made from over the mastoid region. This retro-auricular flap is made with its base directed upwards towards the temporal line, its apex is directed downwards and after it has been dissected free it is tamponed into the osseous cavity from behind and above. All the walls of the cavity from which the morbid tissue has been removed which still remain unprotected and also the defect behind the ear are then covered with skin grafts in the usual manner. For the production of the persistent retro-auricular open- ing, Kretschmann's plastic operation may also be employed, the flaps being formed by this procedure according to the Retro-Auricular Opening and Plastic Methods. 365 method recommended by Panse, but in addition to this a skin flap is also formed. This latter flap is made from the dermal surface of the posterior edge of the mastoid opening and is drawn down into the bone cavity by a curved incision in the skin parallel to the back edge of the mastoid wound and extending externally to the line of the hair. A short in- cision is then made from the center of the original incision connecting it with the edge of the mastoid wound, so that two flaps are thus produced which are turned into the osseous cavity from above and below, after they have been dissected loose. Passow, in performing his plastic flap operation, at first makes the Stacke flaps in an inverted manner from the pos- terior wall of the fibro-cartilaginous canal and then turns the flap which is thus made in an upward direction against the upper wall of the mastoid cavity, where it is held in posi- tion by the usual gauze tampon and the short edge of the flap is joined to the cut border of the concha. Following this a skin flap is formed from the tissue over the mastoid process which is turned up so that its posterior border is brought into contact with the parts remaining of the lower wall of the external canal, the tissues being held together here by gut sutures. The anterior edge of this flap is then sutured to the posterior border of the mastoid opening and the open area remaining as the result of cutting this flap away is brought together and sutured in the usual manner, while the cut edges of the concha which still remain are covered by the skin of both surfaces of the auricle. In those cases where it is necessary to see every part of a large osseous cavity and a post-auricular opening is not de- sired, Grunert and Zeroni have devised a method of obtain- ing a permanently large meatal opening, so that if necessary the mastoid wound can be closed at an early period This is accomplished by making a longitudinal incision the entire 366 Suppuration of the Middle Ear. length of the membraneous auditory canal and carrying it outwards far into the concha. The conchal end of the in- cision is then allowed to granulate to a slight extent, but not to the degree that firm cicatricial tissue is produced and the meatus thus formed is gradually subjected to daily dilatation with tampon and speculum, so that after a time a large round external opening to the canal is obtained. They have devised a specially constructed speculum for the purpose of dilata- tion, it being almost a cylinder in form and is much larger than any of the specula usually employed by the otologist, and as the parts should be redressed daily so that the cavity may be treated and cleansed and a new tampon inserted, the specula is introduced at each treatment and allowed to remain for a short space of time, until the meatus has reached the large size desired. On account of the soft granulation tissue filling the incision in the concha, the parts here are extremely extensible and readily submit to the dilatation, so that both the cartilaginous meatus and canal permit of a rapid increase of their size without any very serious disfigurement nor later contraction as one might naturally expect. When the meatal opening has been dilated to a sufficient size, all parts of the osseous cavity can be readily seen through it and the dilata- tion must be continued until this has been accomplished. The retro-auricular opening should be maintained at first, so that through it those portions of the cavity can be examined which can not be seen through the meatus before it has been sufficiently dilated and it is also wise to keep it open for a time at least, so that one can see that the tampons are care- fully placed, although these should be inserted through the meatus. In several cases where Grunert allowed the mas- toid opening to heal by primary union, considerable difficulty later arose, as perichondritis, with or without small localized pus collections, developed in the neighborhood of the external auditory canal and so narrowed it temporarily that it became Retro-Auricular Opening and Plastic Methods. 367 impossible to see the interior of the osseous cavity to any extent and at the same time the employment of the large speculum for purposes of dilatation had to be temporarily abandoned. The further treatment of the mastoid opening varies entirely with the degree of dilatation that is obtained of the meatus, and as this becomes larger in size, the latter opening may be allowed to contract, so that it will be still of sufficient size to allow those parts to be visible which can- not be seen through the auditory canal. Finally, when the entire osseous cavity can be seen in all its detail through the now enlarged meatus, the retro-auricular opening may be allowed to close completely by omitting the tampon here, for if it be tamponed frequently so that its borders do not become covered with a firm layer of epithelial cells, it may be maintained at practically any size that may be desired and for an indefinite period of time. The retro-auricular opening following the radical opera- tion for chronic suppurative otitis has a value that is some- what problematical and the presence or absence of such an opening depends in many cases to a very great extent upon the particular views held by the surgeon in this respect. Passow states that the ideal aim of the radical operation is the suppression of the suppuration by the complete epidermi- zation of the whole cavity which forms the operative field and the preferable method is that which reaches this object most surely and rapidly. He believes that primary union destroys almost completely the results of the operation; that late suture offers but little more advantage, but that the free retro-auricular opening should be preserved in order to place the patient beyond the chances of recurrence and danger and to facilitate the after treatment. When the surgeon is abso- lutely sure that after a radical operation he has removed all the diseased tissues in every respect, then in such cases the retro-auricular opening is not at all necessary or even desir- 368 Suppuration of the Middle Ear. able, but unfortunately one cannot always be sure that so perfect an operation has been performed, especially when there has been a great destruction of the temporal bone with cholesteatomatous formation, and under these circumstances it is wiser to maintain such an opening for a year or more at least. Among the main objects for the maintenance of such an opening, the simplicity of the after treatment which it affords is of importance, every portion of the osseous cavity is open to tamponage and all the minor depressions and irreg- ularities can readily be seen, and if diseased, treated, while secondary operations if necessary are easy to perform. In the average case it rarely requires more than three or four months to obtain a perfect recovery, and if the opening be made as small as the necessities of the case will admit, but little deformity will be noticed. In the great majority of cases the main object of maintaining the retro-auricular opening is the fear of the redevelopment of cholesteatoma, and when this condition is present in any suppurative case, it is often necessary to maintain the opening until every par- ticle of the epithelial proliferation has been removed and there remains no tendency to its recurrence. Politzer states the objects of the posterior opening as follows: endeavor to bring about a persistent opening behind the ear lined with epidermis when there is extensive cholesteatoma in the mas- toid, by which the greater part of the mastoid is destroyed and a cavity reaching far posteriorly and superiorly is formed, as such an opening enables us to remove cholestea- tomatous deposits resulting from the process of epidermi- zation and which lie in the recesses of the cavity better than by way of the external auditory canal, the patient also being better enabled to wash out the ear and thus preventing the formation of crusts and deposits of epidermis. The same author also states that when there are cholesteatomatous masses, when the antrum is markedly widened posteriorly EXPLANATORY NOTE TO PLATE XXXIX. This plate shows the first step in the performance of the Passow-Trautmann plastic operation for the closure of a persistent retro-auricular opening. 370 PLATE XXXIX EXPLANATORY NOTE TO PLATE XL. This plate shows the second step in the performance of the Passow-Trautmann plastic operation for the closure of a persistent retro-auricular opening. 372 PLATE XL EXPLANATORY NOTE TO PLATE XLI. This plate shows the third step and completion of the Passow-Trautmann plastic operation for the closure of a persistent retro-auricular opening. 374 PLATE XLI Retro- Auricular Opening and Plastic Methods. 375 and superiorly, and when there is a great loss of substance of the vertical portion of the mastoid process, it is better at first to leave the wound open so it can be closed later by suture, if favorable, or allowed to close by itself, the tem- porary keeping open of the wound affording a better chance of observing the course of the opening, more easily treating it and in addition one can obtain a general view of the effects of the treatment. Various methods of forming the retro-auricular opening have already been described in detail and it may be seen as a general principle that should the surgeon desire the wound in the mastoid process to remain open, it is essential that he use pedunculated grafts of various sorts and that the tampon be applied directly through the opening, while in cases where this is not desired, skin grafting may be used to obtain an early closure, which will take place quite rapidly if the tam- pons of gauze are employed exclusively through the meatus. Reinhardt found in cholesteatoma that where the opening rapidly closed a new formation and disintegration of epi- thelial tissue set in, while in those cases where the opening was retained this never happened, his methods of main- taining the opening in such cases being by means of flaps of skin from the patient's head, by transplantation from ani- mals and by means of grafts from the posterior surface of the concha. As previously stated, the main object of the retro-auricular opening is to obtain the complete epidermi- zation and which lie in the recesses of the cavity, better than exposed by the operation. It is readily appreciated that the more this is covered with epithelium the more rapid healing will take place and the less bone that thus is exposed, the less will be the danger of its further destruction by the carious process. In all these plastic operations it is an in- variable rule that the more epidermis that is placed in the cavity, the more rapidly and promptly will the process of epidermization take place. 376 Suppuration of the Middle Ear. A method of producing this result, which has been suc- cessfully employed consists in making a U-shaped incision beginning in front of and extending around the tip of the mastoid process and the dermal layer thus incised is dissected up so that it forms a flap with the base above. The periosteal layer is then dissected away in the same manner except that it is cut completely across at the top and base is formed below; thus two flaps are produced which can -be tamponed into the cavity made in the bone after all the diseased tissues have been chiseled and curetted away. Should the skin over the mastoid process be much involved, or for any reason it is not considered advisable to employ it for such purposes, flaps may be taken from the tissues of the cervical region, or another method which is sometimes applicable, is to dissect up a skin flap from the surface posterior to the mastoid and by turning this back- wards the underlying periosteum may be turned up as a flap, with its base at the posterior border of the opening in the bone, when it may be then packed into the cavity and the skin flap overlying it is then replaced in its normal situa- tion. The use of periosteal flaps alone for lining the cavity in the bone is however not to be recommended, as by their use in this way one does not obtain the desired epithelial surface, but when used in connection with dermal flaps they may often prove of value in covering the bare bone until epidermization extends from other centers. With aseptic technique and the consequent thoroughness with which ex- tensive portions of the temporal bone can be removed, the necessity for a permanent retro-auricular opening in many cases is steadily diminishing, especially as there are many serious objections to it, not the least of which is the disfigure- ment produced. While this latter objection is not so marked when the opening is small, yet it holds good in a large open- ing and in the latter instance there also exists a certain ten- EXPLANATORY NOTE TO PLATE XLII. This plate shows the first step in the performance of the Mosetig-Moorhof plastic operation for the closure of a persistent retro-auricular opening. 378 PLATE XLII EXPLANATORY NOTE TO PLATE XLIII. This plate shows the second step in the performance of the Mosetig-Moorhof plastic operation for the closure of a persistent retro-auricular opening. 380 PLATE XLIII EXPLANATORY NOTE TO PLATE XLIV. This plate shows the third step in the performance of the Mosetig-Moorhof plastic operation for the closure of a persistent retro-auricular opening. 382 PLATE XLIV EXPLANATORY NOTE TO PLATE XLV. This plate shows the completion of the Mosetig-Moorhof plastic operation for the closure of a persistent retro-auricular opening. 384 PLATE XLV Retro-Auricular Opening and Plastic Methods. 385 dency to relapse of the suppuration. Vulpius believes that it is neither desirable nor necessary in the treatment of cho- lesteatoma to retain an opening behind the ear and this belief is being more and more coincided in by many otolo- gists, while in contradistinction to the permanent opening are the advantages of the primary union of the post-aural in- cision, in that it is not necessary to have the patient wear the bandages for any long period of time and that he can go about his occupation within a very short time after the opera- tion. A great objection to the retro-auricular opening is the necessity for frequent dressing and tamponing and espe- cially the excessive pain which is thus daily produced by the majority of methods commonly employed, the recent trend of opinion in this respect being that except in exceptional cases there is no absolute need for the maintenance of the retro-auricular opening, and with some of the modern plastic methods of lining the osseous cavity from the tissue of the membraneous auditory canal, a complete view of the parts through the somewhat enlarged meatus can be obtained with a permanent cure of the chronic suppurative otitis. The time at which the opening behind the ear should be closed will depend entirely upon the amount of diseased tissue that still remains, or the degree of cicatrization of the cavity in the bone. It is as a rule safer to err on the side of safety, and allow the opening to remain longer than necessary than to close it at too early a period. A point which may be of value in deciding this, being the size of the meatal opening, as when this is of a size sufficient to see and treat all the interior of the operative field, then there is no necessity for retaining the post-auricular opening. When a low grade of osteitis continues after the operation, it is of course necessary to keep the opening patent until the osseous tissue again reaches a normal condition and no evidences of suppuration can be found by the most scrupulous examination and the cavity 26 386 Suppuration of the Middle Ear. of the wound is covered with a firm, dry, adherent epithelial lining which is not eczematous and does not produce an excessive amount of desquamation. When cholesteatoma has been present and the posterior opening has been main- tained to prevent its redevelopment, one can not definitely say in advance in any given case the time at which the open- ing may be allowed to close, some operators considering that after one or two years, if there has been no return of the trouble, it will be safe to perform a plastic operation for its closure, but it should always remain open in every case in which it is employed until there is absolutely no sign of the re- turn of additional cholesteatomatous formation. As has been previously pointed out, the time that it takes for the epiderm- ization of the cavity depends to a considerable extent upon the plastic operation which has been employed, that is, upon the amount of healthy epithelial tissue that has been placed in the wound and has successfully "taken," but even then when this has been accomplished, only after continuous observation for a long time, when one is sure that the des- quamation is but trifling and that new deposits of prolifer- ating epithelium can be readily removed through the external auditory canal can the cavity behind the auricle be safely closed, Passow stating that when there is cholesteatoma he closes the fistula after the lining has remained healthy and free from irritation for six months or a year, while in those cases where eczema is intractable or the superficial layer of the epithelium still persists in excessive proliferation, the opening is allowed to remain indefinitely. In order to permanently close the retro-auricular open- ing skin grafting may be employed by any of the methods previously described, or the plastic operations of Lermoyez, Trautmann or Politzer have been successfully used in a number of instances. The procedure employed by Lermoyez and Mahn is performed under general anaesthesia. The Retro-Auricular Opening and Plastic Methods. 387 side of the head is shaved and rendered surgically clean in the usual manner previous to operation. Posterior to the opening in the mastoid process, the skin is incised through to the periosteum about a half centimeter above the cavity; a second incision identical to this is made in the same posi- tion below. These are then joined by two other incisions, so that a trapezium-shaped figure is formed and the skin is then dissected up well into the cavity in the shape of two wings ; these are then turned inwards so that they are brought into apposition with each other across the opening in the bone, where they are united by sutures, so that the fistula is completely occluded. Where, in order to accomplish this, considerable tension of the soft tissues takes place, it becomes necessary to make a semilunar incision over the mastoid about ten or fifteen millimeters from the border of the original posterior incision and the usual antiseptic dressings are then applied. Healing as a rule takes place in less than a week, and a firm dermal covering over the opening in the bone is produced, so that the cavity communicates with the exterior only by means of the external auditory canal and the auricle is not displaced in any way, but remains in its normal position. Trautmann's operation (see plates XXXIX, XL and XLI) for the same purpose is also performed under a general anaesthetic and after the operative field including the retro-auricular opening has been thoroughly cleansed and sterilized, the cavity is then carefully packed with gauze through the external auditory canal to protect the parts against the entrance of blood. An incision about four millimeters long is then made in the center of the upper and lower edges of the bone opening and extending into the cavity in the direction of its long axis for two milli- meters. A second incision is then made, commencing at the upper incision in the posterior periphery of the sinus and 388 Suppuration of the Middle Ear. terminating in the lower part of the original incision, while another incision is made in exactly the same manner at the anterior periphery. The two incisions thus made should be placed at a distance of four millimeters in the middle of their course from the anterior and posterior edges of the retro- auricular opening and should extend through to the perios- teum behind and to the perichondrium in front. The pos- terior flap thus formed is loosened with the elevator and drawn forwards over the cavity in the bone, while the ante- rior flap is loosened from the tissues beneath with the scalpel and drawn backwards to meet the posterior flap. As the tensity of the cutaneous tissue prevents the proper approxi- mation of the flaps for the final suturing, it becomes nec- essary to loosen up the soft tissues over the mastoid for this purpose, and when this has been accomplished, both the ante- rior and posterior flaps are turned into the opening and isolated, when sutures are placed twice into their longitu- dinal axis, so that a total of four sutures are placed in both the anterior and posterior flaps. When the sutures are placed in the longitudinal direction but little difficulty is ex- perienced by using the ordinary slightly curved needle, but when they are placed in the horizontal direction from side to side, even with a sharply curved needle, great difficulty is usually experienced. The ligatures, which may be designated as number two, are then held by an assistant while number one are tied, then number four are held while number three are tied, and finally number four are tied after this has been done with number two. These ligatures should be of catgut, while the skin over the wound is sutured with sik. The gauze which has been placed in the osseous cavity is then removed and a fresh gauze packing is placed by way of the external auditory canal, while an aseptic dressing is applied over the entire ear and allowed to remain in position for five days. As a rule the skin incisions heal by first inten- Retro-Auricular Opening and Plastic Methods. 389 tion and when the dressings are first changed, it will be found that the gauze packing in the canal has been moistened with a bloody serum. The second dressing is then allowed to remain in place for two days, and at the termination of one or two weeks the gauze will be found to be perfectly dry, while the field of operation has become permanently cica- trized and smooth, so that when the auricle is retracted the entrance to the external auditory canal becomes considerably widened and the various parts of the bone cavity can be readily seen. Other methods which have been successfully employed by Politzer and described by him are as follows: A tongue- shaped flap larger than the defect is outlined below the retro-auricular opening on the skin of the mastoid in the lateral cervical region and at the edges of the line mark- ing the flap, a border free of epidermis and about two mil- limeters in width is made. The flap is then dissected up as far as the edge of the defect in the bone, to which it is connected by a broad pedicle, and to make sure that the flap will unite with the edge of the defect, the circumference of the opening is deepened two millimeters in a furrow-like manner by a pointed bistoury. The flap is then turned up, and after its edges have been brought into the furrow around the defect in the bone, it is fixed by four sutures. The epi- dermal surface of the skin flap is thereby turned inwards, that is, towards the wound cavity, and the defect from the removal of the flap is covered by uniting the edges of the incision in the skin, while the external raw surface of the flap is covered with Thiersch grafts or allowed to cica- trize. This method is known as the Mosetig-Moorhof opera- tion (see plates XLII, XLIII, XLIV and XLV). Politzer also advised the employment of Passow's method, which is performed under local anaesthesia by the injection of Schleich's solution. When the tissues are anaesthetized, an 390 Suppuration of the Middle Ear. oval incision is made around the edge of the opening down to the bone behind and the cartilage in front, and the skin is pushed towards the wound cavity on the one hand and away from it on the other, so that two movable skin flaps are constructed: an internal one within the cavity and an ex- ternal one outside of it. The internal flap is then invagi- nated into the wound cavity so that its epidermal surface faces inwards and the two edges are united by a single line of sutures. In the same way the external skin flaps are drawn together by sutures until they meet and are then united, this latter method only being indicated when the opening in the mastoid process is small, as when it is of larger size it is not always possible to bring the edges of the external flap together. CHAPTER VII. AFTER TREATMENT OF MASTO1D OPERATIONS. 391 THE AFTER TREATMENT OF MASTOID OPERATIONS. When the radical operation has been performed, in order to obtain a permanent cessation of the discharge in a case of chronic suppurative otitis media, or after any variety of procedure removing osseous tissue for the same end, it is always of great importance that both the surgeon and patient fully realize that the operation is but the beginning of the treatment, as the later dressings and care of the parts con- stitute an essential link in the chain of success, the object of the after treatment being the complete epidermization of the cavity formed by the operation, by the formation at first of a healthy layer of granulation tissue covering the osseous walls and the development of an efficient barrier, so that any pyogenic process remaining or newly forming after operation will not extend to more vital parts. Not only should the cavity in all its parts be protected by a firm layer of epithelial cells, but this should be perfectly smooth and also remain unchanged in order that no secretions form, or excessive epithelial desquamation takes place, a secondary object, both of the operation and after treatment, being the conservation of the hearing as far as possible, although this factor cannot 393 394 Suppuration of the Middle Ear. naturally assume any great importance if the parts be exten- sively destroyed by the suppurating process and a very rad- ical removal of considerable osseous tissue becomes neces- sary. As regards the radical operation, opinions vary con- siderably as to the final outcome on this point, some operators considering that the hearing is not further impaired, while others believe that in the large number of cases tinnitus is not produced as is sometimes suggested, and the hearing is to some extent improved. It seems that in the majority of cases, at the most, it is not rendered worse, although the patient should always be cautioned previous to operation that there is a possibility of its being greatly impaired as the result of the surgical procedures. Probably the most light upon this aspect of the subject is given in the studies of Grossmann, who in two hundred and sixteen cases of the radical operation, found that with an intact labyrinth the operation improved the hearing in 48.5 per cent., especially when the deafness had been considerable, while in 20.2 per cent, there was no alteration and in 31.3 per cent, it was diminished. In 49.5 per cent, of the cases where the tests showed the full integrity of the inner ear to be wanting, it remained unchanged, while in 38.8 per cent, of these there occurred a fair amount of improvement in the hearing and in such cases a diminution of hearing following the opera- tion and the after treatment is most unlikely, as it occurred in but 15.3 per cent, of the cases. Following the dressing of the wound at the time of opera- tion, which has previously been described, it is advisable that a large bandage be used to hold the dressings in place and protect the parts, this being especially requisite when the cavity in the bone is to be allowed to remain patulous for a considerable period of time. As the patient is very apt to disturb the outer dressings for the first few hours after operation, it is necessary that the bandage be firmly yet com- After Treatment of Mastoid Operations. 395 f ortably applied, so that the opposite ear remains uncovered ; a very satisfactory bandage for this purpose being one ex- tending from the front to the back of the head and beneath the lower jaw, so that it forms repeated turns of a figure of eight. In very restless individuals or in young children, it will be necessary to further secure the bandage for a short time with strips of adhesive plaster, and while some surgeons prefer the use of a starch bandage for the first dressing in such cases, yet this is usually very uncomfortable and where its stiff edges come in contact with the skin it is apt to pro- duce considerable irritation, so that as a rule it is wiser not to employ it. As the healing of the wound progresses the retaining bandage may be made still lighter, while in many cases Koerner's dressing will be found most satisfactory, as it leaves the non-operated ear entirely free and makes no pressure upon its upper portion, as is so often done by other bandages, it being applied by first fixing the roller by sev- eral turns around the forehead and occiput and then repeated turns are taken over the ear, forehead and the nape of the neck, until the operated area is entirely protected. In radical mastoid operations in general, the original dressing should be allowed to remain unchanged for four days to a week, so that granulation is well advanced and the first dressing is rendered less painful, but care should be taken that it is not retained for too long a period on account of the ten- dency of exuberant granulation tissue to grow into the meshes of the gauze packing. Should untoward symptoms occur, however, such as marked pain, a rise of temperature or excessive purulent secretion, so that the bandages become saturated, the dressings should be changed at once, but as regards the temperature, if it does not exceed one hundred degrees for three or four days, or if higher than this, is only temporary, it is not necessary for this reason alone to make any change. In many cases it will prove advantageous to 396 Suppuration of the Middle Ear. remove the original dressings in a shorter time than this, for as a rule there is no necessity for retaining the first dressing any longer than the requisite time to allow the flap to become securely attached to the osseous walls, a period of four or five days often being sufficient for this purpose. - Following the original redressing and during the course of the after treatment, should the wound run a normal course with rapid healing and a minimum amount of secretion, about every three days will be a sufficient time to remove the gauze dressings and repack again, while if the secretion be very profuse they must be changed daily, and under no circum- stances should the dressings be allowed in such cases to remain unchanged for more than forty-eight hours. The time at which the bandages should be entirely dispensed with will depend upon the nature of the operation performed, and will of necessity differ in even every case of the same operation, this question being decided entirely by the degree of repair of the parts and the completeness with which the cavity in the bone is filled with healthy granulation tissue in the simple opening of the mastoid, or the epidermization of the parts in the more radical procedures. After the simple mastoid operation, it is as a rule only necessary to keep the patient in bed a week to ten days in the average case, but when the radical operation has been performed, especially if the removal of the morbid tissue has been at all extensive, the patient should remain in bed for at least one week, and longer if the dura or lateral sinus have been exposed, while in those cases where there are evidences of even mild septicemia before operation, or where the wound is running an irregular course with a rise in tem- perature, local pain or other untoward symptoms, the patient should be confined to bed for an indefinite period, or as long as any unfavorable local or general symptoms are at all manifested. After Treatment of Mastoid Operations. 397 It is essential before each dressing that the parts adja- cent to the wound should be carefully cleansed and ren- dered as aseptic as possible by any of the methods familiar to the surgeon; a very satisfactory procedure, however, for this purpose being to wash the parts with a warm physiologic salt solution and then gently mop with alcohol, the advan- tages of this being that the tissues may thus be rendered thoroughly clean and the dangers of additional infection practically eliminated, while at the same time no irritation of the tissues around the wound in the mastoid will result. If desired, however, in cases where there is a purulent dis- charge, probably excessive in amount, a weak bichloride solu- tion, boric acid, or salicylic acid solutions may be employed for the same purpose by mopping over the parts with a gauze sponge or cotton tuft, but in all cases strict asepsis during this change of dressings is essential, and as far as possible this should approach that carried out during the operation in its thoroughness. It is also especially important that the hands of the surgeon when dressing the ear should be thoroughly cleansed, and that the instruments, dressings, and whatever may be brought into contact with the ear, be rendered perfectly sterile, it being advisable in cases where any pus still remains to use separate forceps for removing the gauze packing from the ear and also for replacing it with fresh sterile gauze. In the simple opening of the antrum when the mastoid wound has not been closed at the time of the operation, if there be but little discharge and that of a serous character at the first removal of the external dressings and the parts are covered with healthy granulation tissue with absolutely no evidence of any diseased tissue, a local or general anaes- thetic may be employed, preferably the former, and the mas- toid wound may be closed with sutures. This procedure shortens by a considerable time the healing process and the 398 Suppuration of the Middle Ear. after treatment, but in the majority of cases a certain risk is necessarily taken, as a small area of tissue in the cavity which still remains may later break down and suppurate, so that it will necessitate the reopening of the wound. In the great majority of these cases, however, it will be better to allow the wound to fill up by granulation tissue from the bottom, and then it is essential that the passage between the wound cavity, antrum and tympanum be kept free from excessive granulation tissue development which is apt to become exuberant in this space, as long as the suppurative process in the tympanic cavity continues. To keep these parts free it may be necessary from time to time to curette the granulations away at this point, although as a rule, if the carious bone has been thoroughly removed, this will not be found to be necessary. In a considerable number of these cases unhealthy granulations are apt to develop on the edges of the incision in the skin and prove a serious annoyance by partially or completely closing the entrance to the cavity in the bone, and when such a tendency is found to be present, one should always thoroughly curette the parts until the granulations have been entirely removed. While in the radical operation the mastoid cavity and the external auditory canal are thrown into one space, so that local treatment to one necessarily implies that the other must also at the same time be treated, such is not the case in the simple mastoid operation, and it is essential that the tym- panic cavity be treated as may seem best in the individual case, at the same time as the treatment of the wound in the mastoid process. When the simple mastoid operation is per- formed in suitable cases where by this procedure the limited amount of morbid tissue can be thoroughly removed and free drainage established, the suppuration rapidly ceases and the opening in the mastoid quickly fills with firm granulation tissue, so that complete healing takes place within a few weeks. After Treatment of Mastoid Operations. 399 After Stacke's operation the patient should be confined to bed for about a week if the conditions are favorable, although quite a number of cases require absolute rest for only four or five days, when they may then go about as usual except that for some time longer active exercise must not be indulged in until the wound has completely cicatrized. In the majority of cases it becomes necessary to change the outer dressings the day following operation, as they are usually saturated with blood stained serum, but the gauze dressing may be allowed to remain for several days longer if no unfavorable symptoms are present. At the end of from five to eight days granulation tissue should be fairly well developed and then the first dressing may be made by re- moving the rubber tube and the gauze packing and replacing the latter with fresh gauze, as usually by this time the flaps are readily retained in position and it is not necessary to replace the rubber tube. Following this in the average case, it is not necessary to change the dressings of tener than every third or fourth day, while the incision behind the ear usually heals in from two to three weeks. At any time during the course of the after treatment, but more especially during the first week after operation, should the temperature rise and continue high, the dressings should be removed and the cause of the fever sought, as a rule the most common causes being small pus collections in the cavity, or under the subcutaneous tissue or periosteum in the neighborhood of the mastoid wound. As a rule when the secondary pus collections are found they are usually present near the upper portion of the incision and if such a condition is found here and the pus evacuated with the temperature still remaining above normal, more thorough search should be made in the deeper portions of the osseous cavity and especially in the neighborhood of the sigmoid fossa or in the vicinity of the antrum. It should be remembered, however, that in occasional cases after the 400 Suppuration of the Middle Ear. Stacke or any other operation, a post-operative temperature may result from some general disease also present, or from local trouble elsewhere in the body and may bear no relation at all to the mastoid wound which careful examination shows is running a perfectly normal course. The care of the patient upon whom a Stacke-Schwartze Or other similar radical operation has been performed, is identical in many respects with that described previously, the dressings being varied somewhat, dependent upon whether the retro-auricular opening is to be closed immediately by primary union, later by granulation, or is to be permanently maintained as an open fistula. In the few cases where primary union may be effected, great care must be taken in concluding the operation that all morbid tissue above and behind the antrum should be most thoroughly removed, as in the subsequent healing of the parts these are usually the last to be protected by firm epithelium, and it will often be found that even after the cavity has been tamponed for sev- eral months these parts will continue to show some granu- lation growth and purulent discharge, often for a long time after other parts of the cavity have undergone resolution. In addition to firm packing to overcome this, it will often become necessary to gently curette this area through the widened canal, and from time to time, if the granulation tissue becomes excessive, it may also be cauterized, while it is very essential that free drainage be constantly maintained. After the radical operation in the case free from untoward symptoms, the first dressing should not be changed before the seventh or eighth day, and if skin grafts have been placed on the walls of the cavity, as previously described after the method recommended by Bench, the entire cuta- neous wound will be found to have united. At the end of this time in such cases the gauze strip and cotton pledgets are removed from the canal. The canal is then lightly dusted After Treatment of Mastoid Operations. 401 with aristol, the meatus is loosely packed with gauze and a light antiseptic external dressing is applied over all the parts. After this the dressings should be changed about every second day. When this method of skin grafting is not adopted and the wound is normal, the method of tamponing the cavity varies, usually after the third week, as determined whether secondary closure of the mastoid wound is to be effected or a persistent retro-auricular opening is to remain. If the latter is desired, the tampon should be applied to the cavity through the mastoid opening until the epidermis lining the interior of the cavity has become continuous with that cov- ering the external surface of the mastoid process, when prac- tically a single skin surface exists over the entire region here, while in those cases where it is desired to obtain sec- ondary closure after the suppuration has greatly diminished in amount or ceased entirely, usually after the third to fifth week, the cavity should then be packed by way of the external auditory canal, and if this be inaugurated before the epi- thelial surfaces of the interior of the cavity have come into communication with the external skin surfaces, the cavity will gradually diminish in size and finally close completely, so that but a slight cicatrix will remain. In all these cases where cholesteatoma has been removed, one is very apt to find an excessive proliferation of epithelium forming well up in a posterior and superior recess of the osseous cavity after the walls have become fairly well covered with a firm epithelial layer ; under these circumstances the deposit at this point should be removed as soon as it forms and the recess must be lightly tamponed with gauze, so that it may become obliterated with healthy granulation tissue. It is essential in any mastoid operation for chronic otorrhcea that thorough drainage be maintained as long as any secretions are present in any part of the wound cavity and only when one is sure 27 402 Suppuration of the Middle Ear. that the suppuration, especially in the deeper parts of the wound, has entirely ceased, may the drainage, either by means of rubber tube or gauze be removed. Under no cir- cumstances, therefore, should the posterior wound be allowed to heal while suppuration in any degree continues, and the communication between the deeper parts of the tympanic cavity and other portions of the wound in the bone should be kept free by constant drainage. As an aid to drainage, if the purulent discharge be very profuse, irrigations may be employed each time the dressings are changed, the solution employed being allowed to flow from the opening behind the ear out through the external auditory canal, but if there be not much secretion present it is better as a rule to avoid the use of irrigations. At the first dressing, however, irrigation is not only of decided value, but is often necessary in order to remove the gauze tampons which have become adherent to the raw surfaces and produce a great deal of pain in their removal; in addi- tion to this the irrigation is of service, as the flaps made from the membraneous canal tube are not always firmly adherent to the underlying tissues, and unless the dressings are thus loosened in this manner they are very apt to adhere to the flaps in part and tear them away. After this, how- ever, in the majority of cases subsequent irrigations are un- necessary, unless they be indicated by the presence of such untoward signs as pain, fever or other septic symptoms, when a two or three per cent, solution of lysol may be used, or a weak bichloride or diluted peroxide of hydrogen solu- tion may be employed for the same purpose. When for any reason it is desired to irrigate, and some surgeons employ irrigation in nearly all cases, in such cases where the secre- tions are not excessively profuse or offensive, the most satis- factory solution for this purpose is warm sterile water, or if this it not desired, a physiological salt solution will be found serviceable. After Treatment of Mastoid Operations. 403 After the radical operation, great care must be exercised in the conduct of the after treatment relative to the develop- ment of granulation tissue, as it is desired that the osseous cavity should not heal by becoming filled with granulations, but that they should form a firm surface over its entire walls in order to act as an efficient basis for the development of the epithelial covering. In order to accomplish this result it is necessary that an antiseptic condition of the wound be maintained and exuberant granulation growth prevented. This latter can be accomplished to a great extent by firmly packing the entire cavity with gauze, so that every crevice or corner is also protected in this manner, usually aristol or plain sterile gauze being most preferable for this purpose. Should the packing be too tight, the development of a proper granulating surface will be prevented or inhibited, and should this be the case, as a rule, the walls of the cavity will show only a slight inclination towards granulation, so that it will be necessary to pack very loosely until an even granulating sur- face has developed. Excessive growth of this tissue may also be controlled by keeping the parts as dry as possible, removing the secretion with gauze mops instead of irrigating and pack- ing every day, while cauterization of patches of exuberant development here and there may be occasionally required, chromic or trichloracetic acid being very useful for this pur- pose. If it becomes necessary to cauterize a large area, the use of chromic acid will not be advisable, but whatever may be employed should be preceded by the cocainization of the tissues and the cauterization should be repeated at intervals of several days, until a healthy surface has been obtained. In another class of cases, where the development is still more excessive, so that cauterization will not be sufficient to con- trol them, it may become necessary to curette the parts occa- sionally, when the proliferating granulations should be thor- oughly scraped away. In occasional cases one will find that 404 Suppuration of the Middle Ear. particular attention will have to be directed to the region of the horizontal semicircular canal and facial spur which re- mains after the radical operation, as between these parts and the roof of the tympanum there is but a comparatively small space after the granulations have fully formed, and if they are not controlled here both surfaces are very apt to grow together and strong connective tissue bands may later de- velop which cause partial occlusion of the epitympanic space and the antrum, the final result being that the antrum is in communication with the tympanum proper only by means of a small opening in this septum, so that a small pocket is formed in this region, producing a continuation of the sup- puration by constantly reinfecting the tissues from the caseous pus which is apt to become lodged here. As healing progresses normally, the granulating surface, instead of being irregular, becomes smoother and paler in color, and epidermization progresses, which may be aided by the in- sufflation of various antiseptic powders, such as aristol, boric acid, etc. As it is necessary that the mouth of the Eustachian tube be kept sealed in order to avoid additional infection from the nasopharynx, it should be well tamponed when dressing the cavity immediately after operation and during the after treat- ment this should be applied at each dressing until the desired result has been obtained. If this closure is not soon accom- plished as the result of the previous curetting away of its mucosa of the tympanic mouth, it may be closed during the process of healing of the mastoid wound by cauterization, the galvanocautery point lightly touched to the parts usually being sufficient to form the desired barrier at this point. Should epidermization be defective in limited areas, or after newly developed necrosed tissue has from time to time been removed, it may be advisable to place small skin grafts over such parts in order to hasten resolution and produce cessa- After Treatment of Mastoid Operations. 405 tion of the suppuration. Small grafts are sufficient for this purpose and they are applied in the same manner as when employed at the time of operation, the bleeding which some- times takes place from adjoining granulation tissue when they are placed in the cavity being effectually controlled with adrenalin, which renders the secondary grafting a matter of but little time, and while it controls any reactive oozing, which is otherwise apt to take place, it is perfectly harmless to the delicate graft itself. After these small pieces of dermal tissue have been placed in the desired positions, they are carefully protected by small pieces of gauze. Gold leaf or sterilized tin foil may be used to prevent the adhesion of the grafts to the packing. Should it become necessary to apply such a graft to the region of the stapes or oval window either at the time of operation or during the course of the after treatment, one should be careful to avoid placing it directly over these parts, as it is very apt to seriously impair the hearing and this will not only take place at the time the graft is placed here to some extent, but the hearing will become much worse as time goes on if the graft is successful from the epidermis in this location becoming very much thicker. The epidermization of the cavity after the radical opera- tion usually takes a considerable time and requires a great deal of care and attention for three to six months, or even longer in some cases. The tampon must be kept up, how- ever, until the walls have been well covered by the growing epithelium and especially must the gauze packing be em- ployed when adjacent parts are granulating, for if they be allowed to come in contact before a dry epithelial surface has formed at least on one of the opposing parts, adhesions will inevitably form and cause pus retention. After the sur- faces have become fairly well covered with epithelium, the tampons can be omitted from time to time, or permanently in 406 Suppuration of the Middle Ear. some cases, as the exposure to the air greatly aids in the progress of healing, and as previously mentioned, this may also be accelerated by the use of a nonirritating antiseptic powder at this time, especially as such a measure greatly pro- tects the immature epithelial cells from maceration by the secretions. Should grafting be successful at first and the mastoid wound be small, epidermization may be completed in six or eight weeks, but when the wound is very large this occupies a much longer period and it may be a number of months before the parts have entirely become covered. The first appearance of successful epidermization is shown by the extension over the granulating surfaces of delicate white areas from the epithelial grafts and thus producing an in- crease in extent of these grafts. When the condition be- comes well marked, it is better to discontinue the use of iodoform gauze, if such has been employed, and substitute for it either plain or aristol gauze, as being less liable to pro- duce irritation and harm to the delicate epithelial surface. It is only necessary at this stage of healing to tampon the cavity every other day, and if after a time the skin growth sloughs away in part, or lack vitality for further proliferation, the cavity should be carefully cleansed with sterile physiological salt solution and new Thiersch grafts applied without again tamponing, but merely protecting the field with a light gauze and cotton external dressing. Burnett believes that after the radical operation, the sub- sequent treatment should aim towards carnification rather than dermization of the newly formed middle ear cavity, and that this process is to be conducted by way of the external auditory meatus. As the drum cavity, aditus and antrum are mucus lined, the process of nature in healing indicates the advisability of trying to carnify the mucous lining after the resection of the carious bone from these regions, rather than endeavoring to line it with a true skin; skin in such a After Treatment of Mastoid Operations. 407 cavity being heterotopic and observation shows that nature does not adopt this method of healing a suppurating ear. He further states that in general it may be said that true skin is out of place in a closed cavity like the mastoid, there- fore as regards the after treatment of cholesteatoma, it ap- pears more rational to thoroughly remove the heterologous mass and heal the wound cavity from the bottom without a retro-auricular opening. Whenever osseous tissue is removed from the mastoid, the cavity thus formed should be packed with gauze in pref- erence to any other material, iodoform gauze being usually employed at first and afterward replaced with sterile gauze should the former produce irritation or actual eczema, or if excessive granulation tissue growth takes place, as iodoform favors the exuberant proliferation of granulations. Subse- quent dressings, as regards the packing of the cavity, should usually be carried out the same as the first dressing, but it is very necessary that the osseous wound should be firmly packed, as, if this is not carefully carried out, favorable results will be materially delayed. Should the dura or lateral sinus be exposed during the course of the operation, the pack- ing from the rest of the cavity not in relation with these exposed parts should be first removed, and then with the most scrupulous aseptic precautions, the gauze pads can be taken away from the dangerous areas and the parts cleared of secretion by gentle mopping with sterile gauze. After the cavity has been cleansed in this manner, these areas should first be protected at each dressing and a separate piece of gauze used to cover them, after which the rest of the cavity is given the usual attention. When the opening behind the auricle has healed to such an extent that it is desirable to allow it to close, the method of packing should be changed, so that a gradual attempt should be made to pack the osseous cavity by way of the external osseous canal, so that the soft 4o8 Suppuration of the Middle Ear. parts over the mastoid may come together and unite. Should this be accomplished gradually, the depression of the cavity becomes filled out and a fairly smooth surface results with but little disfigurement, but when this cannot be brought about, a permanent posterior opening remains or more fre- quently a deep hollow is formed which slowly becomes cicatrized. Should one or more small fistulous openings persist in connection with the mastoid incision after it has healed along the greater part of its length, but which do not communicate with a bone sinus in any way, they may usually be healed by cauterizing the edges with strong nitrate of silver or tri- chloracetic acid, while in a certain small proportion of such cases where these measures prove ineffectual, the edges of the fistula should be lightly seared with the galvano-cautery, after which healing is usually prompt. Where the radical operation has been performed, the patient should be advised in advance of the tediousness of the after treatment, as in the cases which run the usual favorable course, the average time for epidermization to take place is from three to four months, while in many instances five or six months or more elapse before the middle ear cavi- ties are perfectly dry and free from secretion. In the simple mastoid operation the usual time required for the process of healing is of course much shortened, being from four to six weeks as an average, and during this period the growth of healthy granulations which takes place, gradually makes the osseous cavity much smaller and finally completely obliter- ates it, the external wound in such cases finally healing by a linear cutaneous scar, or there may be a somewhat de- pressed bony cicatrix, to which the overlying cutaneous tissue is intimately adherent. During the after treatment, various unfavorable local symptoms may occur from time to time and retard the process After Treatment of Mastoid Operations. 409 of repair in the tissues, the most important of these being an excessive discharge of pus from the cavity, soaking en- tirely through the dressings. This is usually the result of some carious tissue which has not been completely removed, or, as may be shown by the probe, proceeds from a small pocket filled with purulent material which has been previously undiscovered. If a softened area of bone should at any time be thus found, or if any roughness of the walls of the cavity is present it should be thoroughly scraped away with the curette, cleansed with the usual antiseptic solutions or pref- erably peroxide of hydrogen and the cavity packed with gauze as before. At a much later stage, the development of eczema may cause considerable annoyance, but as a rule this is usually due in susceptible individuals to the iodoform gauze which is employed, and disappears upon its withdrawal, If this irritation of the skin surrounding the wound and also involving the auricle be present, aristol or plain sterile gauze should be substituted and the parts may be dusted with aristol, boric acid or an ointment of yellow oxide of mercury may be very successfully employed, while if at the same time the pur- ulent discharge is profuse, the surrounding tissues should be protected either with lanolin or with the mercurial ointment mentioned. After epidermization has been completed, it is not unusual to find in the vicinity of the antrum or in any recesses of the cavity the formation of scales of epidermis scales or small crusts, which are apt to be productive of at the least considerable annoyance and more frequently of a relapse of the aural suppuration. To avoid this as far as possible, the patient should be looked after and the cavity cleansed by the physician every month or more until this tendency has been entirely removed, while if the condition be present, even though slight, the patient may at home instil alcohol or a solution of boric acid in alcohol into the ear once or twice a week, after previously removing the epithelial debris and 410 Suppuration of the Middle Ear. crusts with peroxide of hydrogen. Some few cases rapidly cease when the ear is washed with a physiological salt solu- tion every week or so, depending upon the necessities of the particular case, while in others a small area of suppuration not involving the osseous tissue remains, which should be treated in the usual manner. In a very few cases after radical operation and during the first or second week of the after treatment, an untoward feature of considerable importance is the appearance of a facial paresis. When this occurs only after the first dress- ing, it is usually the result of pressure or some slight inflam- matory irritation of the facial nerve and in practically all cases disappears after a few weeks without any special treat- ment being indicated. Finally, among the untoward phe- nomena, is the elevated temperature which often occurs after mastoid operations. It is often a most difficult matter to ascertain its cause and in a recent study by Harris of this problem the question in the individual case in which there is a rise of temperature, is whether it suggests an incomplete operation with retained pus or diseased bone, or imperfect asepsis, or whether there is a normally elevated post-opera- tive temperature due to causes which originally produced it. The conclusions in this respect, which he derived from a number of cases, are that a post-operative temperature of moderate amount is customary in mastoiditis; its cause is not known and without accompanying symptoms it means nothing. In such cases, therefore, the rise of temperature, as described, requires no treatment, but in those cases where it is unduly continuous or elevated, the proper treatment is obvious after its cause has been ascertained. INDEX. INDEX. Abscess, acute mastoid, 239 Aditus, length of the, 182; relation of, to the attic and tympanum, 20, 24, plate III Adhesions, between the membrana tympani and the inner tympanic wall, 14, 106; cutting away, when removing the ossicles, 112; surgical treatment of, in the membrana tympani, 44 Adrenalin chloride as a haemostatic, 104; in ossiculectomy, 102 After treatment of the mastoid opera- tions, 393-410 Alcohol, for lessening the secretion from granulation tissue, 161 Alderton's method of searching for the incus, 123 Amberg's signs for indicating the dis- placement of the lateral sinus, 223, 224 Anaesthesia, general, for nervous or restless patients, 39; in mastoid op- erations, 386, 387; in opening the attic, 146 ; local, Schleich's method of, in mastoid operations, 243; posture of the patient during, 103; the ques- tion of, in ossiculectomy, 103 Anatomical and surgical landmarks, 181-226; landmarks within the mid- dle ear relating to diagnosis, 8; as related to the surgical pathology of the middle ear, 10 Anatomical, plate showing inner sur- face of the temporal bone, 198; sec- tion, of the drum membrane and osseous auditory canal, plate II, 16; of facial nerve, ossicles, attic and cerebral fossa, plate I, 12; showing auditory canal as seen from in front and above, plate III, 24; showing facial nerve and foot plate of the stapes, also the Eustachian tube, plate IV, 28; through the temporal bone exposing the inner surface of the membrana tympani and ossicles, plate XXV, 220 Annulus tympanicus, plate XXII, 204 Antrum, as a " drip cup," 237 ; avoid- ing wounding the dura mater when entering the, 270; Broca's statements relative to the depth of the, 199; care in curetting the, 268; caries of 413 414 Index. the, 96; caries of the roof of the, 18; certainty that the, has been opened before curetting the mastoid cells, 264; cholesteatoma of the, 260; con- dition of the, in chronic otorrhcea, 305 ; depth of the, 199, 200 ; distance of the, from the cortex, 264 ; entering the, using the spine of Henle as a guide in, 225; external wall of the, difference of opinion as to the depth, 267; in children, 267; infection of the, 182; locating the, mechanical de- vices for, 251 ; location of the, 186, 251 ; location of the, as a basis for removing diseased tissue, 182; meas- urements of Holmes relative to the depth of the, 199; method of opening the, without breaking down the pos- terior canal wall, 297 ; opening of the, as a primary procedure, 239 ; opening, of the, at the initial point, 191, 192, 2 53> guiding rule for avoiding the lateral sinus in opening the, 260; relations of the, with the aditus and attic, 186; searching for the, 265; size of the, 185; statements of Ker- rison relative to the depth of the, 199, 200; topography of the, 185; variation as to the depth of the, 199; various guides for opening the, 192, 193; Zaufal-Kuster method of open- ing the, 328 Aquseductus Fallopii, plate I, 12, plate XX, 194 Attic, and ossicles, plate I, 12; caries of the, 86; hyperplastic changes in the, 22; morbid changes in the, 22; relations of the, and its walls, 189; relations of the, to the tympanum proper and to the aditus and antrum, 20, 24, plate III ; suppuration of the, involving the antrum and mastoid, 22; suppuration of, involving the malleus and the incus, 22; removal of the incus for suppuration of the, 117; removal of the outer wall of the, 142, 143; removal of, with the cylindrical burr, 145, 146 Atticitis, external, 144 Audition better where the posterior wound heals from the bottom, 327 Audition, care in grafting to prevent impairment of, 405 Auricle, attachments of the, 225, 226 B Ballance's mastoid operation, 333; technique of, 334, 335, 336 Bergmann's modification of the mas- toid operation, 331, 333 Biehl's method, 329 Blake's method for healing the wound after mastoid operation, 274 Bleeding, see HEMORRHAGE. Blood clot method (Blake) of closing the wound after mastoid operations, 274 Bone, amount of, removed by the cu- rette in radical operation, 306, 307; destruction of, and danger of in- fection in opening up diploetic tis- sue, 271 ; diseased, in tympanic walls, 6 (see also under CARIES) ; surfaces, covering the, with flaps after radical operation, 308, 309, 310; surfaces, newly formed, epidermal covering of the, 307, 308, 309; temporal, plate XX, 194; pathological changes in the temporal, in mastoiditis, 281 Broca, statement of, as to the depth of the antrum, 199 Buck, mastoid hook of, for locating the antrum, 251 Burr, electric, advantages of the, in opening the mastoid cortex, 271 ; cooling of the, to avoid necrosis, 321 ; for leveling down the facial spur, 320; use of, for grinding down os- seous tissue, 319, 320 Calcification of the ossicles, 101 Canal, external auditory, antiseptic measures a necessity in after treat- ment of operations on the, 159; caries and necrosis of the, 26; stricture of Index. the, leading to pus retention, 281 ; cocaine anaesthesia of the, 38; de- fects of osseous continuity of the upper wall of the, 14, 15; depth of the, 26; object of operative pro- cedures by way of the, 5, 6; opera- tions through the, 151-176; plate I, 12; preparing the, for operation, 36, 37; external semicircular and Fal- lopian, considered in relation to aural suppuration, 200, 201 ; protecting the, in mastoid operation, 314; horizontal semicircular, position of the, 207; semicircular, course of the, 200, 201 ; semicircular, plate XXI, 198; wall, postero-superior, length of, in esti- mating depth of the Fallopian and horizontal semicircular, 196, 197; re- moving the posterior canal wall with chisel, gouge and cutting forceps, 301 Caries, and necrosis of the pneumatic spaces, 260; local anaesthesia in ex- ploring for, in the external auditory canal, 26; of the antrum associated with cholesteatoma, 96; of the attic walls, 17, 86; of the external audi- tory canal, 26; of the handle of the malleus, plate XI, 76; of the head of the incus, plate XII, 90; of the head of the malleus, 18; of the incus, 18, 22 86, 90; of the mal- leus, 22, 86, 90; of the middle ear, 18; of the tip of the manubrium, 17; of the tympanic walls, 6 ; of the walls of the antrum, 260; use of the elec- tric burr for removing, 321 Carious changes, knowledge of, im- portant in selecting form of opera- tion, 98 Carnification by way of external audi- tory meatus after radical operation, 406 Carotid artery, internal, plate XX, 194 Catarrhal changes in the Eustachian tube, 17, 28, plate IV Cauterization, of the edges of fistulous openings after partial healing of the mastoid incision, 408; of the mucosa, 55 ; of the tissues of the tympanic cavity, 65, 66 Cell groupings, nature of, in relation to important structures, 190, 191 Cell infiltration, 53, 54 Cells, aberrant, in the mastoid process, 212, 213; endothelial, origin of, 77; mastoid, plate 1, 12 ; cholesteatoma of the, 260; hypertrophy of, 260; pet- rous, 212; squamous, 211; pneu- matic, of the mastoid process, 211, 214, plate XXIV; pus, encapsula- tion of, 14 Channel operation, double, 320; single, 320 Chisel, use of, in removing bone in mastoid operations, 254 Cholesteatoma, after treatment of (when removed through the canal), 165-168; formation of, 327; most frequent sites of, 78; of the an- trum and mastoid cells, 260; retro- auricular opening not desirable in, 385, 386; skin transplantation to pre- vent formation of, 327; Stacke oper- ation for, 288, 299; surgical treat- ment of, 79 ; two groups of, 74, 77 Chromic acid in treatment of base of polypi after their removal, 160, 161 Cocaine, as a local anaesthetic, 38; and adrenalin chloride, as a local anaes- thetic in ossiculectomy, 102 Completed simple mastoid operation (Schwartze) on a bone specimen, plate XXIX, 266 Complete radical operation (Stacke- Schwartze) on a bone, plate XXX, 284 ; Stacke-Schwartze operation, with an exposure of the sigmoid sinus and the dura of the middle cerebral fossa, plate XXXII, 316 Cortex, mastoid, use of the electric burr for opening the, 271 ; opening in the highest point of the, 253; size of the opening, 258; re- moval of, by instruments, 254; sur- face of the, appearance of the, in 416 Index. mastoid operation, 208; varying thickness of the, 208 Curette, use of, for removing polypi, 72 Curetting, for opening the cortex, 254; in after-treatment of mastoid opera- tions, 398, 400, 403; of the tympanic mucosa, 55, 56, 57; raw surfaces after operations, Bonain's method of, 163; removing the outer attical wall by, 143, 144, 145; tympanic walls after ossiculectomy, 57 D Degeneration, fatty, 54 Dench, method of, for removing the incus, 123; method of, for removing the malleus, 114, 113; method of, in skin grafting after radical opera- tion, 310, 311, 312, 339, 340 Dermal flaps, see SKIN FLAPS Destruction of the long process of the incus, 94 Discharge, purulent, as a symptom of the pathological conditions, 9; cessa- tion of, after operation, 175; from perforations of the tympanic mem- brane, 17; irrigation as an aid to drainage in, 402; treatment of, after operations, 163-165 Drain, object of the, in after treatment of operation through the canal, 172, 173 Drainage, after ossiculectomy, 167; in chronic otorrhcea after operation, 401, 402; wick, 281 Dressing, 167, 274, 313, 314; gauze drain for, after ossiculectomy, 167; of the mastoid wound, changing the first, 400, 401 ; of the wound after sim- ple mastoid operation, 274; the cav- ity after radical operation, 313, 314 Dressings, 160, 167, 172, 313, 314, 400; after operations, 172; sterilization of, in mastoid operations, 232 "Drip cup," the antrum as a, 237 Drum-membrane. See MEMBRANA TYMPANI Dura mater, avoiding wounding the, in entering the antrum, 270; granu- lation of the, 61 E Ear, closing of the opening behind the, in mastoid operation, 385, 386; drum of the, enlargement of the perfora- tion of the, 46; operation for dis- secting away the drum of the, from inner tympanic wall, 53; internal, plate, XXI, 198; middle, after treat- ment of operations on the, 161, 162; anatomical landmarks as related to the surgical pathology of the mid- dle, 10; anatomy of the middle, 10-13; caries of the middle, 18; cholesteatoma of the middle, 74; pathological alterations of the mid- dle, 19; surgical treatment of the middle, 68-131 Eburnation of the mastoid, 260 Eczema occurring during after-treat- ment of mastoid operations, 409 Electric burr, advantages of the, in opening the mastoid cortex, 271 ; cooling of the, to avoid necrosis, 34; for grinding down osseous tissue, 319, 320; for leveling down the facial spur, 320 Empyema, 238 Encapsulation of cholesteatomatous material, 14; of pus cells, 14 Epidermic scales, formation of, dur- ing the after-treatment of mastoid operations, 409 Epidermization, in limited areas, skin grafting to aid, 404, 405; method of producing complete, 375, 376; of the cavity after the radical operation, 405, 406; of the cavum tympani after operation via auditory canal, 346 Epitympanic regions, curetting, through the canal, 145 Epitympanum, treatment of caries of the, 135-154 Eucain as a local anaesthetic, 39 Eustachian tube, catarrh of the, 17; Index. avoiding infection of, from the naso- pharynx, 404; cleansing of nares and nasopharynx to avoid infection of the, 169; osseous opening of, plate XX, 194; sealing mouth of, to avoid infection from the nasopharynx, 404 Evisceration, of the entire affected mastoid for proliferation, 261 ; of the mastoid and tympanic contents, 5 Evulsion of polypi, 72 External cortex of the mastoid re- moved and the mastoid antrum opened, plate XXVIII, 25 External surface of the temporal bone of the new-born infant, plate XXII, 204 F Facial nerve. See Facial NERVE. Fallopian and external semicircular canal considered in relation to aural suppuration, 200, 201 Fenestra ovalis, plate XX, 194 Fenestra rotunda, plate XX., 194 Fistula of the mastoid process, 326 Fistulous openings, cauterizing the edges of, after partial healing of the mastoid incision, 408 Flaps, skin, 308, 309 ; Bench's method of forming, 339, 340; making of Kuster, 338, 339; manipulation of, during mastoid operation, 248 Forceps-chisel, removing external wall of the attic with the, 143, 144. 145 Forceps, cutting, for removing granu- lation tissue, 62, 63 Formaline, solution as an antiseptic in after-treatment of operations, 161 Fossa, cerebral, plate I, 12; glenoid, plate XXII, 204 ; middle cerebral, 316 (plate XXXII) ; spine of Henle in relation to middle cerebral, 196; cra- nial, avoiding the, in mastoid opera- tion, 226; variation in depth of, 224 G Gauze drain, use of, after ossiculec- tomy, 167; drainage, several factors 28 to be remembered in using, 172, 173; to stop the oozing after curettage, 173 Gellee's modification of the mastoid operation, 330 Gold leaf to prevent adhesion in graft- ing, 405 Gouge, use of, in removing the cortex in mastoid operation, 254 Grafting, 345-390; skin, avoidance of overlapping in, 336; care in, to pre- vent impairment of hearing, 405; Dench method of, in after-treatment of radical operation, 310, 311; in Bal- lance's mastoid operation, 335 ; Panse method of, 347, 348; parts that should be especially protected in, 336; to hasten resolution and prevent sup- puration, 404, 405 Granulation, of the tympanic mucosa, 56; removing, from canal or tym- panic cavity, 37; surgical treatment of, 61 ; tissue, after-treatment of, in radical operations, 403; curetting of, in after-treatment of mastoid opera- tions, 398; exuberant, lessening the secretion of, 161 ; reduction of, by antiseptics before operation, 8; re- moval of, by cutting forceps, 62, 63; removing, from the surface of the antrum, 13 Granuloma of Prussak's space, 62 Grunert-Zeroni, plastic method of, 365, 366 H Healing after radical operation, 406; curetted surfaces with boracic acid, 162; of the wound after simple mas- toid operation, 274 Hearing better when the posterior wound heals from the bottom, 327; care in grafting to prevent impair- ment of, 405 Hemorrhage, 272-274; control of, dur- ing simple mastoid operation, 247; control of, in ossiculectomy, 104, 108, 126; control of, in removing the 4i8 Index. bone in the region of the sinus, 269, 270; control of, while excavating the mastoid interior, 272; from stripping up the periosteum, 217; treatment of, from the wound after mastoid opera- tion, 272-274; venous, during simple mastoid operation, 248 Henle, spine of, as a guide for opening the mastoid, 192, 195; as a land- mark, 216 ; situation of, 195 ; varia- tion of size and appearance of, 195 Herpes, facial, from cauterizing the mucosa, 57 Hiatus Fallopii, plate XX, 194 Holmes' measurements of the antrum, 199 Hooks, incus, Ludwig*s, 125; various forms of, 123 Hyperplasia of the dermoid layer, 54, 55 Hypertrophy of the mucous membrane of the antrum and mastoid cells, 260 Incudo-stapedial joint, cutting away the, before removing the incus, 118 Incus, 300, plate XXXI; accidents in removing the, 126, 129; Alderton's method of removing the, 123 ; caries of the, 18, 22, 86, 90, 100; Bench's method of removing the, 123; destruc- tion of the, 98; destruction of the long process of the, plate XII, 94; hooks, various forms of, 123 ; Kretch- mann's method of removing the, 124 ; loss of topographical position of the, 90; Ludwig's method of removing the, 125; methods of searching for the, 120-125; removal of the, 116-117; re- moval of the, in mastoiditis, 92, 119, 120; Zeroni's method of removing the, 125 Infiltration, cell, 53, 54 Instruments, used in performing ossic- ulectomy, 105; sterilization of, for operation, 232, 397; surgical cleanli- ness of, used in operations, 160 Internal surface of the temporal bone of the new-born, plate XXIII, 210 Irrigation, as an aid to drainage in after treatment of mastoid opera- tions, 402; of the wound previous to packing after radical operation, 313; of wounds after operation, 273 Jansen-Stacke flap operation, plate XXXV, 356; plate XXXVI, 358; plate XXXVII, 360; plate XXXVIII, 362 Joint, incudo-stapedial, cutting away the, before removing the incus, 118; most frequently affected in chronic suppuration, 99 K Kerrison, statements of, relative to the depth of the antrum, 199, 200 Koerner, flap operation of, 348, 353; modification of, 354; plate XXXIII, 350; plate XXXIV, 352; technique of, 353, 3545 treatment of wound after radical operation, 395 Kretchmann, method of, for removing the incus, 124; plastic operation of, 364, 365 Kuster method of making skin flaps, 338; original method of entering the tympanum, 337 L Large perforation of the drum mem- brane, with caries of the handle of the malleus, 76, plate XI Lateral sinus, various theories as to the position of the, 221-224 Lemoyez-Mahn method of plastic op- eration, 386, 387 Leutert's classification of chronic sup- purative otitis media, 18 Linea temporalis, as a landmark, 215; position of the, 216; prominence of, in children, 216; surgical aspect of the, 216 M Macewen triangle as a point of election for entering the antrum, 192 Index. 419 Mahn-Lemoyez's method of plastic op- eration, 386, 389 Malleus, caries of the, 22, 86, 90; ca- ries of the head of the, 18; Bench's method of removing the, 114, 115; detection of caries of the, 100; handle of the, plate XXII, 204; re- moval of incus and, for free drain- age in attical suppuration, 91 ; re- moval of the, 113-116 Mastoid, cavity, cleansing the, before operation, 262, 263 ; packing the, with iodoform gauze after removal of os- seous tissue, 407; cells, plate XX, 194; cells, distribution and varia- tions of the, and their relation to sup- purative otitis, 208 ; cells, hypertrophy of the, 260 ; changes, 238 ; changes, in children, as influencing operation in otitis media, 267; contents, extent of the removal of the, in operation, 263, 264; fistula, 326; formation of the, 267, 268 Mastoiditis, acute, 237, 238, 259; dur- ing tympanic suppuration, 28 Mastoiditis, in young children, 267, 268; pathological changes in the tem- poral bone in, 281 ; removal of the incus in, 92 Mastoid operation (in general), after treatment of, 393-410; various un- favorable local symptoms occurring during, 408, 409; antiseptic meas- ures in after treatment of, 397 ; avoid- ing the middle cranial fossa in enter- ing the antrum in, 226; drainage after, 401, 402; facial nerve and the lateral sinus in relation to the, 25, 200; rule for general anaesthesia in, 243; importance of the lateral sinus in, 218; indications for, 100; modifi- cation of, 325-341 ; Panse modifica- tion of the, 328; preliminary prepara- tion of the patient for, 229-233; Randall's method of performing the, 202, 203; Schleich's local anaesthesia in, 243; source of danger to the facial nerve in, 25; sterilization of instruments and dressings in, 232; upper limits of the field of the, 216; use of the electric burr in the, 271 Mastoid operation (radical), 279-321; advantages of, for tympanic suppura- tion, 285; after-treatment 0^393-410; care of patient after, 400, 401 ; car- nification by way of the external au- ditory meatus after, 406; choosing the, from a pathological aspect, 241 ; closing the incision after, 312, 313; curetting in the, 303, 304; differentia- tion of opinion as to audition after the, 394; disadvantages that may militate against the, 286; facial par- alysis after, 317; facial paresis oc- curring during after-treatment of, 410; general conditions which indi- cate, 281, 282; impairment of hear- ing after, 286; importance of the facial nerve and the external semi- circular canal in the, 314; in caries of the antrum associated with choles- teatoma, 96; indications for, 241, 242, 280-282; Kuster's modification of the, 337, 338; making the opening through the cortex in, 222; modifica- tion of, when cholesteatomous masses are found, 318, 319; object of main- taining the retro-auricular opening in the, 362, 363; objects of the, 285; packing the cavity after, 313, 314; pain on change of dressing after, 3 J 3> 3 J 4; plastic method after, for covering the bone surfaces, 308; pri- mary union in the, 366, 367 ; removal of diseased tissue in, 306; retro- auricular opening, maintenance of the, in, 385; retro-auricular opening, problematical value of the, in, 367; success of the, depending upon the cavities being kept free from in- fection, 304; technique of skin graft- ing in, 310, 3". 312; time required for the process of healing after the, 408; variation in the treatment of 420 Index. the opening in the, 367; various methods of closing the incision in, 312, 313; Waring's method of filling in the opening behind the ear after, 340; when to close the retro-auricu- lar opening in the, 385, 386; Zaufal method of, 287 Mastoid operation (simple), 237-276; a basis for the radical operation, 238, 239; after-treatment of the, 396, 397, 398; Blake's treatment of the wound after, 274; completed, on a bone specimen, 266, plate XXIX; con- trol of hemorrhage during, 247, 248; curetting tympanic cavity be- fore, 263; difference of opinion in regard to the Schwartze method for, 239; dressing the wound after the, 273, 274, 397; healing of the wound m > 397! indications for the, 241, 242; manipulation of flaps in, 248; mean- ing of the term, 238; object of the, 238; opening of the antrum in, 239; primary incision in, 244, 247, 250, plate XXVII ; removing the cor- tex in, 254; retro-auricular incision in, 244, 245, plate XXVI; time required for the process of healing after the, 408; treatment of the wound after, 272, 274; variation of opinions as to results in curing otor- rhcea by the, 275; use of the chisel in, 254 Mastoid process, classification of the, 207, 208, 209; diploetic character of, plate XXV, 220; eburnation of the, 260; eburnated type of, rule for re- moving the bone of, in operation, 226 ; pneumatic type of the, 207, 208; sclerotic changes of the, 326; scle- rotic type of the, 208 ; site for entering the, 191, 192; structure of the, in re- lation to the temporal bone, 207; variation of the pathological changes in the, 259; vascular association of the cranial contents and the, 217; venous relations of the tympanic regions and the, 217 Membrana tympani, adhesions between, and the inner tympanic wall, 14; after-treatment of operations on the, !58, 159; enlarging the perforations in suppuration of the, 44, 45 ; indica- tions for second perforation of, 46; perforations of the anterior segment of, 17; technique of operation for perforation of, 44; posterior perfora- tions of the, 17; removal of adhe- sions between the tympanic wall and the, 46; removal of, for adhesions, 53; sterilizing the canal in operation in the, 44; surgical importance of perforations of, 18; treatment of perforations of the, 44; thickening of, in long-standing suppuration, 54 Membrane, drum, retracted, plate VI, 50; plate VIII, 60; see MEMBRANA TYMPANI; caries of Shrapnell's, 86, 87; difficulty in locating minute per- forations in, 21 ; perforation in, plate X, 70 Meninges, exposure of the, during op- eration for chronic otorrhoea, 270 Meningitis developing from an ab- errant pneumatic cell, 215 Modification of mastoid operations, 325-341 Moorhof-Mosetig plastic operation, plate XLII, 378; plate XLIV, 382; plate XLV, 384 Morbid changes, in eighty consecutive cases where the radical operation was performed, 305, 306; in the mu- cosa, 53 Mosetig-Moorhof plastic operation, plate XLII, 378; plate XLIII, 380; plate XLIV, 382; plate XLV, 384 Mucosa, granular changes in, 55-57; morbid changes in the, 53, 54; reten- tion of pus by the folds of the, 19 Muscle, stapedius, cutting the tendon of the, 119, 126, 127 N Necrosis, local anaesthesia in exploring for, in the external auditory canal, Index. 421 26; of the tympanic walls, 151; su- perficial, in chronic suppuration, 152 Nerve, facial, 300, plate XXXI; and the lateral sinus in relation to mas- toid operation, 200; and the spina, distance separating the, 206; angle of the, in adults, 205 ; course of the, 200, 201 ; danger to, in mastoid op- erations, 25 ; descent of the, 205 ; exposed, plate I, 12; in young chil- dren, 205 ; local inflammation of, after cauterization of the mucosa, 57 ; paralysis of the, during the after- treatment of mastoid operations, 410; position of the, 203, 206, 207 ; protect- ing the, in radical mastoid operation, 3M Normal temporal bone with a pro- nounced convexity of the mastoid process, plate XVIII, 184 Obliteration of all cavities in radical operations, 307 Operation, intratympanic, anaesthesia in, 38; of synechiotomy for evacuation of pus, 66 Operations, by way of auditory canal, object of, 56; mastoid. See MAS- TOID OPERATIONS ; preliminary prep- arations of the patient for, 35-39; through the external auditory canal, cardinal principles in the after-treat- ment of, 159 Osseous, cavity, watching the, in after- treatment of radical operation, 320; walls, applying flaps to the, after radical operation, 308-310; walls, treatment of, after curetting, 170 Ossicles, and attic plates, 12; calcifica- tion of the, 101 ; facial paralysis in removal of the, 129; removal of. See Ossiculectomy ; the treatment of the, 85-131 ; Vacher's method of re- moving the, 128 Ossicular landmarks, localizing accu- rately, 13 Ossiculectomy, accidents liable in, 126, 129; adrenalin chloride as a haemo- static in, 104 ; anaesthesia in, 102, 103 ; certain limitations of, 97; cessation of discharge after, 175; contraindica- tions for, 19; control of hemorrhage in, 126; essentials for successful re- sults in, 7, 8; final results (as to amelioration or cure) of, in sup- puration, 130, 131 ; first step in, 106- 108; for free drainage in attical sup- puration, 86, 88, 91 ; gauze drain after, 167; general anaesthesia in perform- ing, 38, 39; general constitutional treatment after, 174; in attical sup- puration, 86; indications for, in at- tical suppuration, 86-97; inflamma- tory symptoms following, 175; pain from blood clots after, 173, 174; Politzer's classification of conditions for performing, 96; technique of, 102; variation in the technique of, to suit different conditions, 101 Osteitis, chronic proliferative, 259 Otitis media, chronic suppurative, ad- vantages of operation by way of the auditory canal for, 6; associated with impairment of the hearing, 130; Bal- lance's operation for, 333, 334; caries in> 305 ; formaline solution in treat- ment of, 166; formation of new bone in, 259; treatment of, by simple mas- toid operation, 267; intratympanic operation for, 6; Leutert's classifica- tion of, 18; operative treatment of, through the post-auricular route, 182 ; Ossiculectomy in, 92; pathological changes in, 237; permanent cure for, 6; Politzer's indications for opening the mastoid in, 240, 241 ; removal of polyps with forceps in, 78; removal of the incus in, 92; Schwartze's operation in, 240, 241; Stacke- Schwartze operation in, 293; treat- ment of, after operation, 165, 393; when to open the mastoid in, 240, 241 422 Index. Otorrhcea, 8, 9, 140, 318, 401, 402; chronic, avoiding the exposure of the lateral sinus in operation for, 318; condition of the antrum in, 305; drainage in, after operation, 401, 402; dressing the wound after mastoid op- eration for, 273; facial palsy in, 80; indications for operation in, 85, 86; loss of the incus in, 120; removal of polypi and granulation tissue in, 73; variation of opinion in curing, by the simple mastoid operation, 275 ; from infection of the nasopharynx after operation, 304; odor of dis- charge in, 9; preliminary treatment of, 9 P Packing. See TAMPONING Pain after ossiculectomy, blood clots the cause of, 173, 174; Ballance's modification of the mastoid operation to avoid, 334; in change of dressing after radical operation, 313, 314; mas- toid, an indication for radical opera- tion, 282; relief of, in chronic sup- puration, 80; syringing after opera- tions for, 164 Panse, method of grafting, 347; modi- fication of mastoid operation, 328 Paralysis, facial, after mastoid opera- tion, 317; from too forcible use of the the incus hook, 125, 129 Paresis, facial, occurring during after- treatment of mastoid operations, 410 Partially completed Stacke-Schwartze operation, plate XXXI, 300 Passow, plastic operation of, 365 Passow-Trautmann plastic operation, plate XXXIX, 370; plate XL, 372; plate XLI, 374 Perforation, into the tympanic mem- brane, after-treatment of, 158 Perforations, and their significance, 18, 19; minute, difficulty in locating, in Shrapnell's membrane, 21 ; surgical treatment of, in the membrana tym- pani, 44 Periosteum, stripping of the, hemor- rhage from, 217; treatment of, dur- ing simple mastoid operation, 247; treatment of, in the Stacke opera- tion, 289, 290, 296 Peroxide of hydrogen treatment to control pus formation, 171 Physiological salt solution in irriga- tion of wound after mastoid opera- tion, 273, 410 Plastic flap methods, 345-390 Politzer's, classification of conditions that specially indicate ossiculectomy, 96; classification of the local causes of caries of the tympanic walls, 147; methods in plastic operation, 389, 390 Polyp, aural, plate X, 70; formation, 77; cauterizing the base of, after re- moval, 68; different methods of re- moving, 71-74; in chronic tympanic suppuration, 66, 67 ; multiple, removal of, with forceps, 78; removal of, by cold or hot snare, 67; removal of, from the tympanic roof, 68; remov- ing, from canal or tympanic cavity, 37; surgical treatment of, 61, 67 Preliminary preparation of the patient for operation, 35-39 Primary incision carried through the skin and periosteum, soft parts re- tracted, showing underlying bone, and field of operation, plate XXVII, 250 Probe, caution in using the, in lesions of the tympanic walls, 136, 137; use of the, in locating carious areas, 145 ; use of the, in reaching the antrum, 251 Prussak's space, 14; granuloma of, 62 Pus, cells, encapsulation of, 14; course of, from antrum and mastoid cells, 95; course of, from the attic, 95; course of, in suppuration of the tym- panic walls, 142; retention of, by folds of the mucosa, 19; secondary, collections, 399; synechiotomy for evacuation of, 66 Index. 423 R Radical mastoid operation. See under MASTOID OPERATIONS. Randall's method in performing radical operation, 340; theory in regard to the lateral sinus and its surround- ings, 218 Reinhart method of plastic operation, 376 Retractors, use of, in mastoid opera- tion, 248 Retro-auricular opening after radical operation, keeping the wound free by, 313; and plastic operations, 345- 390 Ridge, temporal. See LINEA TEMPOR- ALIS s Sagittal section of the mastoid proc- ess and tympanic cavity, plate XIX, 188; on a plane with the facial nerve, plate XX, 194 Scales, epidermic, formation of, dur- ing the after-treatment of mastoid operations, 409 Schematic drawing of the removal of the malleus, with the forceps in po- sition, plate XIV, no; of the in- cus, after the completion of the re- moval of the malleus, plate XV, 117; side view of the tympanic cavity showing an adhesive process between the drum membrane and promontory, 51 ; retracted cicatrix and intra-tym- panic relations, plate V, 48; tympa- num showing necrosis of the handle of the malleus and a polypus, 119; view of the tympanum illustrating cutting of adhesions between the promontory and drum membrane, plate VII, 52; showing necrosis, plate XVII, 138; Schwartze operation in distinction to the radical, 239 Schwartze-Stacke, the, operation. See SXACKE-SCHWARTZE OPERATION. Sequestrum of bone, removal of, from the tympanic cavity, 152, 153 Shrapnell's membrane, perforation of, 14, 17, 170, plate X Siebermann, plastic method of, 364 Silver salts in after-treatment of opera- tions, 160, 166 Sinus, lateral, abnormalities in position of, 221, 222; accidental opening of the, in chronic suppuration, 268; and the facial nerve in relation to mastoid operation, 200; asymmetry of the skull as a cause for displacement of the, 223, 224; dangerous area of the, 222; guiding rule for avoiding the opening of the sinus in mastoid op- eration, 269 ; methods for locating ac- curately the, 223; normal position of the, 221 ; variation in size and po- sition of the, 218 Sinus, sigmoid, 316, plate XXXII Skin flaps, 308, 327; making of Kuster, 338, 339 Skin, irritation of the, during after treatment of mastoid operations, 409 ; transplantation, 310-312, 327 Skull, asymmetry of the, 223, 224 Snare, cold, for removing polypi, 67; hot, for removal of polypi, 67 Space, hypotympanic, situation of, 13; Prussak's, 14; granuloma of, 62 Spina and facial nerve, distance sep- arating the, 206 Spine, of Henle, as a landmark, 216 ; in relation to the middle cerebral fossa, 196; variation of size and appear- ance of, 195-196; suprameatal, as a guide for opening the mastoid, 192, 195; situation of, 195 " Spongy spot," 191, 225 Squamous plate, plate XXII, 204 Stacke-Jansen flap operation, plate XXXV, 356; plate XXXVI, 358; plate XXXVII, 360; plate XXXVIII, 362 Stacke operation, advantages of, in radical mastoid operation, 287, 288; after-treatment of, 399; disadvan- tages of the, 288; primary step in the, 289, 290; special indications for, 288; technique of, 292, 293 424 Index. Stacke, plastic methods of, 363, 364 Stacke-Schwartze operation, 284, plate XXX; advantages of the, 292, 293; care of the patient after the, 400, 401 ; eradication of the cause of otitis media by the, 293; in choleste- atoma, 289; modification of the pri- mary incision of, 295; primary in- cision over the mastoid in, 293, 294, 295 ; technique of the, 292-295 ; treat- ment of the periosteum in the, 296 Stapes, 300, plate XXXI ; danger of re- moving the, in suppurative condi- tions, 127, 128; operative procedures on the, 126, 127 Suppuration, attical, 22, 86; chronic, Bergmann's operation indicated in, 331 ; division of, into three classes, 97; relief of pain in, 80; skin grafting to hasten resolution and prevent, 404, 405; Stacke or Zaufal operation in, 259; use of the chisel in opening the antrum for, 268-270; Stacke's method for the radical cure of, 287; mastoid, when to operate on, 280 Suprameatal spine, as a guide for open- ing the mastoid, 192, 195 ; as a land- mark, 186; situation of, 195 Suture, squamo-mastoid, importance of as a landmark, 215 ; locating the, 215 Suturing the incision after mastoid operation, 273, 274, 312 Synechiotomy for evacuation of re- tained pus, 66 Syringing for removing debris and pur- ulent secretions from the ear after operation, 163; indications for, in pain after operation, 164 Tamponing, injury to the facial nerve from too tight, 317; mouth of Eu- stachian tube to avoid infection from the nasopharynx, 404; the mastoid cavity after radical operation, 313, 314, 401, 405 Tegmen tympani, plate I, n, 12 Temperature, elevated, after mastoid operations, 410; in after-treatment of mastoid operations, 399 Temporal bone, cerebral surface of the petrous portion of the, plate XX, 194; topography of the, 224; varia- tion of, in the child from that of the adult, 224 Tenotomy of the tendon of the tensor tympani muscle, in, 112 The after-treatment of operations through the external auditory canal, IS7-I76 The radical mastoid operation, 279-321 The retro-auricular opening and plas- tic methods, 345-390 The simple mastoid operation, 237-276 The treatment, of caries of the tympanic walls, the epitympanum and hypotym- panum, 135-154; of the mucosa and muco-periosteum of the tympanic cavity, 43-81 ; of the ossicles, 85-131 Thiersch's grafts, 346, 406 Tissue granulation, after-treatment of, in radical operations, 403; curetting of, 58, 398; removal of, by cutting forceps, 62, 63 Tissues, cauterizing the, of the tym- panic cavity, 65, 66 Transplantation of skin, 310-312 Trautmann plastic operation, tech- nique of the, 387, 388 Trautmann-Passow plastic operation, plate XXXIX, 370; plate XL, 372; plate XLI, 374 Triangle, Macewen's, as a guide for opening the antrum, 192 Tube, Eustachian. See EUSTACHIAN TUBE Tympanic, cavity, plate V, 48; anatomy of, 10 ; care of nose and nasopharynx as after-treatment of operation on the 169; cleansing the, after evisceration, 169; cleansing the, with the curette, 303 ; curetting of, diversity of opinion in regard to, 56, 57; pathological changes in the, 101 ; removal of se- questrum of bone from the, 152, Index. 425 !53; ring, examination of, after cu- retting, 153; walls, caries of, 6, 152; caries of the, treatment of, 140, 141 ; causes of caries of the, 147 ; curetting of the, 150, 151; curetting, after os- siculectomy, 57; curettage and ex- cision of, for caries, 6; diagnosis of caries in the, 136-139; indications for operative procedures on the, 139 ; indications for removing caries from the, 147, 148; lactic acid applications to, after operations, 171 ; lesions of the, care in using the probe in, 136, 139; smoothing the, in radical opera- tion, 307; thickening of the walls of the, 149; operation for detaching ad- herent membrane from the, 53 Tympanum, caries of the, character- istics of, 141, 142; cholesteatoma of the, 79 ; floor of the, situation of, 13 ; indications for treatment of the, 29; osseous changes in the, 148, 149; removing the stapes in suppurative conditions of the, 127; roof of, sur- gical relations of the, 20; roof of, in chronic suppuration, 10; venous re- lations of the mastoid process and the, 217 V Vacher, method of removing the ossi- cles, 128 Vein, mastoid emissary, bleeding from severing the, in mastoid operation, 217 Vertigo, labyrinthine, radical mas- toid operation in, 282 w Wall, post meatal, care in removing the, 317 " Wick drainage," 281 Wound, dressing of the, after simple mastoid operation, 273, 274; dress- ing of, after the radical operation; 394-401 Z Zaufal-Kuster method of opening the antrum, 328; method compared with Stacke-Schwartze in removing os- seous tissue, 328; method of, in radical mastoid operation, 287 Zeroni, method of, in removing the incus, 125; -Grunert, plastic method of, 365, 366 Zone, vascular, variation of the, 191 Zygomatic process, plate XXII, 204 Oppenheimer , Seymour Sxirgical treatment of chronic suppuration of the middle ear and mastcid MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664