THE ESSENTIALS OF TREATMENT OF ACUTE IN

FLAMMATION OF THE MIDDLE EAR.

BY ALBERT E. BULSON, JR., B. S., M. D., FORT WAYNE, INDIANA.

In the selection of this subject, I am not unmindful of the fact that there is at present a diversity of opinion among otologists as to the essentials of treatment of an acute inflammation of the middle ear; and in giving my personal views, based largely upon observation and experience, it is quite possible I shall advocate some measures which may seem somewhat radical. It is gratifying, however, that the trend of medical teaching today is in favor of more radicalism in the treatment of acute ear inflammations, and that the so-called "waiting policy" in the management of these cases is considered by most progressive otologists as carrying with it a decided element of danger.

Most authors divide acute inflammation of the middle ear into two forms, the catarrhal and purulent. Clinically the two forms should be considered as different stages of the same disease, the difference in the character of the inflammatory process depending upon the presence and activity of the infection and the resisting power of the tissues, features that are always factors in the production and limitation of an inflammation of the middle ear. That every acute inflammation of the middle ear does not end in purulency depends upon the fact that either the micro-organisms necessary for purulency are not there, or if there, are inactive through resisting power of the tissues to invasion of the infection.

Bacteriologic investigations have shown that various microorganisms can produce a similar pathologic effect upon the middle ear, but as a rule the milder forms of middle ear inflammation are produced by the pneumococcus or staphylococcus, and the severer forms by the streptococcus (Nadoleczny). The fact that the milder forms of middle ear inflammation often run into the

severer forms makes it difficult, if not impossible, in many cases to distinguish the two forms of inflammation described by most authors. Neither subjectively nor objectively will the symptoms in a large percentage of cases give evidence of the character of the infection at work, for in some individuals the pain will be very severe and the congestion of the membrani-tympani pronounced in a comparatively mild inflammation, while in others the pain will be mild and the external evidences of congestion not marked in a very severe inflammation.

In probably 99 per cent. of all cases the infection reaches the middle ear through the eustachian tube. Even in healthy individuals the bacteriologic examination of the secretion from the naso-pharynx almost always shows the presence of a certain number of pathogenic bacteria, and in the presence of disease conditions of the naso-pharynx, as in the case of hypertrophoid and degenerated conditions of the lymphoid pharyngeal structures, or inflammation of the nasal and pharyngeal mucous membrane accompanying many of the infections and contagious diseases, the number of pathogenic bacteria are greatly increased.

The extension of bacteria to the middle ear by means of the eustachian tube is accomplished through mechanical means, as from pressure by blowing the nose and swallowing, or by extension of the inflammation through continuity of tissue. Predisposition as well as activity of the infection will in a large measure determine the extent and severity of the inflammation. If the infection is mild the inflammation may not terminate in the suppuration but continue to the end devoid of severe symptoms or manifestations, and as such be classed with the catarrhal inflammations in which the exudation is seromucous in character and the bacteria few in number and of low vitality. It should be remembered, however, that such an inflammation may be transformed into the suppurative type through introduction of more active infection through the eustachian tube, or in case of perforation of the drum membrane, from the external auditory canal. What, therefore, begins as a comparatively mild inflammation, may very quickly pass into a severe inflammation, with all the

attending danger of complications and perhaps loss of life. This transition of one type to the other may be so rapid as to escape early recognition unless the otologist is in a position to watch the progress of the inflammation much closer than is generally the case, and as a result proper treatment may be adopted too late to limit ravages of the disease which might be limited or prevented by earlier attention.

The possibilities of an earache, and a moderately congested eardrum in whole or in part, are not limited to a few hours or days of discomfort and moderate impairment of hearing which a hot water bag and judicious Politzeration will relieve, but include all the dangers which accompany a violent inflammation in a region connected with or surrounded by some of the most vital structures in the body. The recognition of the possible seriousness of every carache and the gravity of every acute inflammation of the middle car, and the necessity for prompt and energetic treatment of such conditions can not be too forcibly impressed upon the minds of general practitioners and public if we are to make any progress in limiting the number of cases of partial or complete deafness, intracranial complications, and fatal results which now frequently follow in the wake of middle ear diseases.

Prophylactic treatment in cases predisposed to middle ear inflammation is too often overlooked or given inadequate attention. The mild earaches which promptly subside under simple treatment or no treatment at all, should lead to an investigation as to the predisposing causes. In the majority of such instances there will be found various forms of diseased conditions of the upper respiratory tract. In children adenoids and enlarged tonsils are a prolific source of middle ear inflammation, while in adults obstructive lesions of the nose are more frequently predisposing factors. Such conditions should be recognized and given prompt attention if we are to do the most to prevent the development of many acute inflammations of the middle ear. Lowered resisting power from the effects of various debilitating diseases should also receive appropriate constitution treatment, while the local treatment of the nose and throat in the exanthemata, influenza and all other in

fectious or contagious diseases in which the mucous membrane is affected, should never be neglected.

In practically every case of acute middle ear inflammation the patient seeks relief because of discomfort or impairment of hearing, or both. Treatment may be instituted which will have a tendency to relieve pain, prevent complications from extension of the diseased process, and restore the hearing. For the relief of pain it would seem superfluous to condemn the use of opiates, and yet as a few text-books recommend such treatment with but little qualification it seems pertinent to oppose it on the ground that opiates mask the symptoms and at times give the patient as well as surgeon a sense of false security. Pain is only a symptom and is of sufficient diagnostic importance to warrant no treatment which will simply obtund it without relieving the diseased condition which is causing it. Dry heat will generally give relief if measures short of operative are to be sufficient to produce the desired results. But as the pain is due to pressure from congestion and exudates resulting therefrom, the essential treatment must come from depletion. This may be accomplished in whole or part by cartharsis, leeching, the application of carbolic acid and glycerine solution to the membrana tympani for its osmotice effect, and direct incision into the congested tissues. When seen early or before the inflammation has progressed to the point where there is marked congestion of all or any part of the membrana tympani, the inflammatory process may often be checked by free purgation, the use of leeches to the tissues immediately in front of the tragus, carbolic acid and glycerine tampons, and the application of heat to the ear. More often, however, the patient does not see the aid of the physician until the membrana tympani is decidedly congested if not already bulging, and then to delay the more heroic measures of incising the drum membrane is to invite complications and prolong the suffering of the patient.

Many otologists of skill and experience recommend waiting until there is bulging of the membrana tympani before practicing incision, and even go so far as to call it pernicious and meddlesome surgery to incise the drum membrane at any other time than when

there is bulging. It is accepted as a fact that sometimes a waiting policy brings with it good results, but there are some of us, who, having seen unfortunate results from the waiting policy, prefer not to take the chances. If we remember the direct connection which exists between the mastoid antrum and middle ear, and the tendency for infection to travel, especially in the direction of least resistance, we can readily understand how the infective process may extend to the antrum without indicating its tendency to extension by bulging of the drum membrane, and particularly in those cases in which the drum membrane is abnormally unyielding, as is not infrequently the case. I have seen mastoid complications which come to operation without there ever having occurred bulging of the drum membrane, and which I am satisfied would not have occurred had early and free drainage through the membrana tympani been established.

When properly done, incision of the drum membrane is appropriate treatment of those cases of acute inflammation of the middle ear, either with or without severe pain, which present marked congestion of either part or the whole of the membrane, and whether bulging or not. By means of the incision depletion of the tissues is secured, the pressure is reduced and the associated pain relieved, required drainage is established, and in the majority of cases mastoid and other complications are prevented. The incision should be free, preferably in the posterior quadrant, and should be performed under strict aseptic precautions. Subsequently the external auditory canal should be packed with a strip of dry sterile gauze, the end of which should be placed against the drum membrane for the purpose of drawing the secretions from the ear by capillary attraction. Due care should be observed to keep infection from entering from without. This can be accomplished by pursuing the ordinary rules of surgical cleanliness when replacing the gauze, as becomes necessary when it becomes saturated with secretion from the middle ear, and keeping the outer ear covered with an aseptic absorbent pad of cotton or gauze. When the discharge from the ear is profuse the gauze will require removal frequently, and before inserting fresh gauze the canal may be wiped dry with sterile cotton wrapped on a probe.