XTbe Bristol

flDeblco==Gblvurgical Journal. Scire est nescire, nisi id Scire alius sciret." "

june,

me

1912.

INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE. A DISCUSSION AT THE BRISTOL MEDICO-CHIRURGICAL SOCIETY, MARCH 13th, 1912. INTRODUCED

J.

BY

Michell Clarke, M.A., M.D.,

F.R.C.P.,

AND

J.

-Dr.

Lacy Firth, M.S., F.R.C.S.

Michell Clarke said:

Without

time

by proceed at once to deal with the most important intra-cranial complications of ear disease, vvhich are, of course, meningitis, abscess and sinus phlebitis.

Preliminary observations,

taking

up

I

Certain symptoms of cerebral disturbance may occur in disease of the ear, especially of the internal ear, only, and the

first step is to determine whether there is actually intra-cranial disease. Even in this preliminary step in diagnosis the decision ^ay be by no means easy. Although the onset of disease of this kind is so often insidious, by the time we are called upon for Such

^?l.

a

decision the symptoms

XXX. No. 116.

are

generally

grave and acute.

98

DR. J. MICHELL CLARKE AND MR. LACY FIRTH

Some assistance may be had from the character of the otorrhoea, for a discharge which is septic is far more likely to lead to intracranial

complications. Very severe symptoms

mastoid disease alone.

may be present in otorrhoea with Byrom Bramwell1 gives severe

Thus

headache, pains radiating over the side of the skull or within the head, vomiting, giddiness, ataxia, nystagmus, and even epileptiform convulsions and optic neuritis, as occurring thus. Such with of ataxia and exception symptoms, nystagmus, giddiness, would, however, disease because

as

the

(1)

the

rather to intra-cranial abscess than

point

The

cause.

patient

difficulty

is too ill

as a

elaborate tests which

are

nystagmus originating

in internal

used to

of distinction is

rule to carry out the rather

distinguish

ear

to ear

increased

the

vertigo

and

disease from those of cere-

although persistent nystagmus on the whole indicates disease of the cerebellum, and (2) because optic neuritis may be present in chronic otorrhoea. Ballance states that the optic neuritis in such cases is of slight intensity, may be present for months without increasing, and subsides on free removal of temporal bone disease. Its persistence, therefore, after a complete operation of this kind would suggest an intra-cranial origin for it. These cases of optic neuritis in ear disease without signs of intra-cranial complication are very important, and 1 hope that subsequent speakers in this discussion may be able to throw some light on their frequency and severity. Their chief bellar origin,

2

importance

lies in the fact that if unrelieved

blindness may result.

There

are

optic atrophy and

further those

neuritis with mastoid disease and indefinite

cases

of

optic

intrasigns cranial complication which lead to so much difficulty. In a recent case of Dr. Firth's (a girl of about eleven years), operated on for mastoid disease, there was optic neuritis, most intense on the ipsolateral side, the head was kept bent towards the same shoulder, and the face turned to the opposite side, together with 1

Allbutt and Rolleston's

of

some

System of Medicine,

vol. viii., 1910, p. 25?'

System of Medicine,

vol. iv.

"Abscess of the Brain." 2

Allbutt and

P- 475-

Rolleston's

part ii., 19?b'

ON INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

lritense headache, vertigo, slight nystagmus, especially

to

9g

ipso-

^ateral side, difficulty in standing, and tendency to fall and to Sta?ger towards the same side. The cerebellum was explored VVlthout result, and the It is also important

SuPpuration in the

child recovered

gradually.

to remember here that there may be

internal

intra-cranial

complication, tympani may be intact. I do not propose to deal with septic sinus-phlebitis, but I should like to ask those ^ith more experience whether repeated rigors and a high temperate of 104? and 105? occur in uncomplicated mastoid or internal ear suppuration, or whether such symptoms are diagnostic of SePtic sinus thrombosis in the absence of tenderness and swelling ?Ver the vein ? jugular ^ this stage of doubt, or of suspended decision as to the Presence of an intra-cranial complication, Sir V. Horsley1 has. 16htly insisted upon the necessity for a thorough neurological .Xamination *-? be carried out and repeated from day to day, ncluding daily observation of the optic discs until a diagnosis is arrived at. ear

and

an

and Vet the membrana

decided that

th

next

point

Present.

an

intra-cranial

complication exists,.

to settle is whether it is due to the

disease

ear

This is not always easy. A patient with chronic may get an attack of influenza or be suffering from

OtorrV, inoea

Ulasmia; in both cases cerebral symptoms may occur which ay closely simulate meningitis, or the latter may be actually

111

|^esent

as

a

consequence of influenza.

Further,

a

child with

?n]c otorrhoea

may develope polio-encephalitis. This affection Specially apt to follow the specific fevers, for instance, measles. easles not infrequently gives rise to middle ear disease and r

but th

bel

SUC^

^at both affections

might

own

the same

wcmld be derived from the

a case

t^ln^ra~cran'al abscess, at any rate, practically

as a

0?

SO

result of recent otorrhoea, but is

Some

standing.

a^ack

n?lrig 1

the

a

Polio-encephalitis,

cerebellum,

to this organ.

when the

cause

knowledge

never occurs

consequence of otorrhoea as

Batten has

shown,

symptoms will be those

Polio-encephalitis is, however,

Proc. Roy. Soc. Med., 1911-12,

v.

(Otolog. Sect.),

45.

a rare

TOO

?disease,

and

complication with otorrhoea would be very frequent and important is the combination of otorrhoea with tuberculous meningitis ; the otorrhoea may or may not be due to tuberculous ear disease. In my experience it is not at all uncommon for patients with tuberculous meningitis to be suffering from otorrhoea, and this is one possible route for tuberculous infection of the meninges. The diagnosis can generally be made, and the independent origin of the meningitis from the otorrhoea determined ; and this is most important, for it saves the patient from possible operation, which could only hasten the end. The chief points in the diagnosis are the history of prodromal symptoms as compared with the acute onset of septic meningitis ; the seat of the meningitis is generally at the base, and the characters of the cerebro-spinal fluid obtained by lumbar puncture, showing a lymphocytosis and the presence of tubercle seldom.

?

DR. J. MICHELL CLARKE AND MR. LACY FIRTH

as

a

More

bacilli. If we have

to the conclusion that

come

?complication directly

due to the

then to determine its nature. ?

ear

intra-cranial

an

disease is present,

Omitting

sinus

we

have

thrombosis, the

distinction has to be made between abscess and

meningitis-

easy, more often it is and there is the further complication that ?extremely difficult, both abscess and meningitis may be present. The signs that Sometimes this

diagnosis

is

would make the

diagnosis

of abscess easy

normal temperature, normal cerebration,

quite

slow and full

are

a

subnormal

slow but

?r

less

pulse, optic neuritis more marked on one side, headache, vomiting, giddiness, apathy, a foul tongue, progressive emaciation, with or without the special signs which a

?enable the abscess to be localised in

one

more or

of its two common

temporo-sphenoidal lobe. In the ?diagnosis of meningitis most important aids are the temperature, the pulse, and the examination of the cerebro-spinal fluid. The temperature in meningitis is raised, in abscess normal or subnormal. This is a point, however, which I hope subsequent speakers will deal with, especially as to the occurrence of a raised temperature in intra-cranial abscess, more especially in its ?early stages. It is certain that reliance on the temperatufe situations?the cerebellum

or

ON INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

alone may lead

c?urse ?ver

of

84.

the

case

a

three acute abscesses in the brain with

were

SuPpurative meningitis Mtra-cranial pressure.

Byrom Bramwell1 quotes

Thus Dr.

to error.

Case in which there

101

at the base and

The temperature

was

the whole

throughout the pulse never a case which suggested

and

subnormal, 2

Dr.

of the

great increase

Logan Turner referred to in the posterior fossa, but in which a cerebellar Meningitis abscess was really present. The cerebro-spinal fluid was turbid, c?ntained albumin and a large number of polymorphonuclear cells. The temperature was high, the pulse rapid, together with ri?idity of the neck, double Kernig's sign, and a leucocytosis of 22.ooo. Post-mortem, a large cerebellar abscess was found

^ing

close

to

the surface of

Meningeal

the lobe

and

into the

leaking

small aperture. No meningitis. spaces through c?uld be detected macroscopically. The greatest aid is obtained fr?m the results of lumbar puncture. In meningitis the cerebroa

sPmal fluid

is

more

Mcreased number, Causative organism 'hus

fully

^ere

less

or

often

turbid,

greatly

contains

so, of

leucocytes,

may be recovered from

cleared up.

In

abscess,

on

albumin,

and

art

whilst the

it, and the cause hand, although.

the other

exceptions, as in the case related by Dr. Logan Urner,3 the cerebro-spinal fluid is generally clear, with no,. ?r only a very slight, increase in the number of cells. Again?. 111 Meningitis the pulse is rapid and often irregular. Optic Ileuritis, if present, is bilateral, and other nervous signs,.

^ch

are

as

any alteration in reflexes that may be present, or in pupils, are bilateral. Kernig's sign I have not

size of the j Urid of

very great value as a distinctive sign. A few words may be said as to the condition known

Meningitis.

This is

effusion into the

as serous

ventricular

meningeal pyogenic focus in their lcinity. According to Dr. Ballance,4 it may be general, but Metimes the serous effusion is locally limited, and this may CCUr 0ver the cerebellum and temporo-sphenoidal lobe, and rise to in the diagnosis from abscess. He saysdifficulty

Paces excited by

an

the presence of

or

a

1

c?

cit.

2

pr0Ci 3

R0y.

Soc. Med., 1911-12, v.

Loc. cit., p.

63.

4

(Otolog. Sect.),

Loc. cit.

p. 62..

1V2

that

DR. J. MICHELL CLARKE AND MR. LACY FIRTH

serous

meningitis

chiefly

occurs

in young

adults,

and that

its

signs are headache, drowsiness, a rise of temperature with a relatively slow pulse, restlessness, vomiting, and a dilated and sluggish pupil. Relief is given by lumbar puncture, the cerebrospinal fluid being under considerable pressure, and containing Lumbar puncture is therefore no excess of or few leucocytes. ?of great value in diagnosis. I do not think it necessary to do more than allude to the ?combination of posterior basic meningitis with otorrhoea, as the

symptoms

are

distinctive,

and lumbar

puncture

establishes the

diagnosis. The symptoms of intra-cranial abscess will differ according to its character, whether it is acute or chronic, and whether it is

encapsuled abscess may give rise symptoms. general symptoms on which I hope subsequent speakers may give information. First, as to the presence of fever in abscess. I gather from the recent encapsuled

to

or

not.

A chronic

There

no

discussion at the

are

Otological

two

Section of the

Royal Society

Medicine that fever is absent, except possibly in the initial stages of abscess. Secondly, as to the value in diagnosis of

vomiting, I have seen it stated that in cases where an abscess extending vomiting is severe and persistent. I am not sufe from my own experience that this is the case. At any rate, two or three cases the vomiting, which had been constant and severe before, ceased shortly after admission to hospital although the other symptoms were unchanged, and I am in' dined to think that the change to the orderly regime of a hospit^ and careful regulation of diet are sufficient by themselves t? check vomiting in some of these cases. Intra-cranial abscess as a complication of ear disease 15 almost invariably, if single, situated either in the cerebellum1 or temporo-sphenoidal lobe, and on the same side as the ear disease. It is worth bearing in mind that with disease in external ear or mastoid the abscess is generally in the cere' is

bellum, and with disease in

sphenoidal

lobe.

.situations may be

The

the

diagnosis fairly easy or

tympanum in

the

temp?r?

between abscess in these so

difficult that,

although

xV'e

ON INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE. are

able to say that

alrriost impossible

IC>3

intra-cranial abscess is present, it is

an

to be certain

In either the cerebellum

or

as

to its

the

abscess

position. temporo-sphenoidal

lobe

an

may be entirely latent. In the cerebellum it will not give rise to characteristic signs if small and so situated as not to P^ss upon the intra-cerebellar tracts of the superior and inferior

cerebellar peduncles

or

of the nucleus dentatus.

In the

temporo-

sPhenoidal lobe there is a large silent area," and unless the at>scess is large, so as to cause pressure upon the Rolandic cortex "

0r

internal

capsule,

concerned with

two-thirds

or

is situated in the

taste and

smell,

or on

of the

tip

lobe, which

the left side in the

is

posterior

of the

superior temporal convolution, the auditory Centre, it will give rise to no localising symptoms. With regard to abscess in the lateral lobe of the cerebellum, ln addition to the general signs of intra-cranial abscess, the

Realising Slmilar

signs,

more

or

to those which

Sltuation,

but

fewer of which may be present,

we

rarely so patient being are

account

of the

disease,

cannot

as a

rule be

look for in

well shown

a

tumour in the

as

in tumour,

are

same

and,

on

acutely ill in abscess from ear thoroughly investigated. Very

more so

?ften we have to be content with what we can find out from those symptoms which can be investigated with the patient in bed, and we are therefore deprived of the assistance *? be obtained in diagnosis of cerebellar disease from the characteristic disorders of equilibration, attitude, position of *he head, and gait. The most important signs are vertigo, 1Ps?lateral paresis of the limbs [that is to say, if the ear disease is unilateral, on the same side as the ear disease], ataxia in the ipsolateral limbs, some ataxy of movement, and *he position of the patient, who lies curled up in bed on the ll0rnial side, and returns to this position when disturbed. With e?ard to the eyes, there may be optic neuritis, weakening of the movement to the ipsolateral side, less commonly y deviate to the opposite side, lateral nystagmus, with Wer jerks of greater amplitude to ipsolateral side. The Pupils are unaffected, unless both are dilated from general rise of ^tra-cranial pressure. There is sometimes paralysis of the Vlth

^njugate

DR- J- MICHELL CLARKE AND MR. LACY FIRTH

104

knee-jerks vary, sometimes the jerk is increased on ipsolateral side ; the superficial reflexes are unaltered. The general signs of an intra-cranial abscess have been mentioned; but the position of headache in cerebellar abscess should be borne in mind, it is very often felt in the opposite frontal region. As to optic neuritis, as compared with abscess in the temporosphenoidal lobe, it comes on earlier and is more intense, and according to Sir Victor Horsley in either case it is more marked on the side of the abscess. The value of paralysis of the Vlth is much diminished by the facts that nerve as a localising sign The

nerve.

the

it is the first

nerve

intra-cranial

the

to suffer in any cerebral affection which raises pressure, that basic meningitis must be

and that it is

excluded,

occasionally paralysed

in

ear

disease

without any intra-cranial complication, as in the case of a boy under Mr. Firth's care whom I saw recently. The position of the

head,

said to be held down towards the

shoulder,

ipsolateral opposite side,

which is turning as a of lesion of a lateral lobe, I do not think is a given sign reliable sign. Its value is especially doubtful in acute ear cases with mastoid operation, for then the head is sometimes kept in this position when there is no intra-cranial complication. In those cases where a patient is very ill, and just able to stand

with

of the face towards the

out of bed with

support,

the side towards which he tends to

fall is not of much aid in diagnosis.

paresis of the ipsolateral arm and leg with absence of facial paresis, a normal or increased knee-jerk, flexor plantar reflex, and normal abdominal reflexes is of great importance in the differential diagnosis from abscess of the temporo-sphenoidal The

paresis due to the latter will be contralateral, and affect the face, the contralateral abdominal reflexes will absent, the plantar reflex extensor and the knee-jerk

lobe, will be

for

increased.

Unfortunately

the

value

of

rendered uncertain in double otorrhcea

determining but where

which

one

ear

ear

is

responsible

this

by

the

distinction is

difficulty oi

for the intra-cranial lesion i

alone is affected the homolateral

cerebellar disease contrasted with the contralateral of

sphenoidal abscess, together

with the other

paresis a

of

temporo-

accompanying and-

ON INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

distinctive signs

of these two lesions

value.

A further caution must be a

hemiplegia,

a

paresis

large size,

very

underlying pyramidal a

with

regard

is of

great

to the characters

that should the cerebellar abscess be chronic

and have attained riSe to

given

respectively,

105.

tract in the

of the

arm

and

it may press upon the

medulla,

leg,

with

and therefore

an

extensor

plantar

reflex and loss of abdominal reflexes on the opposite side. his case some of the cranial nerves would be also involved,

frequent

affection of the Vllth in the

the \ Illth from the

iagnosis

of cranial

nerve

Sometimes most of ^?be of the cerebellum 0ccur.

il ?

e

signs

In

ear

a case

Fallopian

give In but

canal and of

disease itself lessens the value in

paralysis. signs

the above

of affection of the lateral

present in abscess, more often only a that I saw with Mr. Morton some years aero are

0

unusually complete. The patient, a girl of 13, 111 addition to vomiting, persistent subnormal temperature, 9? F., pulse of 84, frequent fits, which suggested the cerebellar type of fit, emaciation, slow cerebration, deafness and discharge 0rri the left ear, lay curled up on her right side in bed, with the right hand under her head, and constantly returned to this Position when disturbed. There were also paresis and ataxy of *he left arm, increased left knee-jerk, slight conjugate deviation eyes to right, nystagmus, with more ample excursions to left, and right frontal headache. Double optic neuritis was present, and it is to note that interesting throughout in this case it was m?st intense in the Mr. Morton right contralateral eye. eVa-cuated a large abscess in the left lateral lobe of cerebellum, ari(I

were

complete recovery

ensued.

With regard to abscess in the temporo-sphenoidal lobe, it be latent, because it lies in the silent area," and this area 0rriprises the greater part of the lobe, or because there is a free "

between ^ornmunication ?ugh which it can

the abscess

discharge.

cavity

and the

Unless the

tympanum

discharge

is for

0lIle rea.son checked, there may then be no symptoms. The appearance of cerebral symtoms when a communication

o_r?nipt ^is kind is blocked is

probably responsible

for the old idea

206

DR. J. MICHELL CLARKE AND MR. LACY FIRTH

that it is

dangerous to cure an otorrhoea. A distinctive sign temporo-sphenoidal abscess is aphasia, in the form of worddeafness, and one symptom is said to be especially common, that is inability to name objects. From pressure upon the neighbouring angular gyrus in these cases there may be also word-blindness. If a true aphasia (word-deafness) can be distinctly made out, it is pathognomonic, and excludes the cerebellum as a possible seat of the abscess. It is, however, a symptom which is only available when the disease is on the left side. Further, when the patient is very ill, suffering from toxaemia or from a general increase of the intra-cranial pressure, of

there may be

a

state of mental confusion which may be mistaken

aphasia, and as the auditory centre only occupies the posterior two-thirds of the superior temporal convolution, it may easily escape damage even when the disease is on the left side. for

For the

same

reason

confined to the

tip

that

of the

the centre

for taste and smell is

lobe, affection

of these

senses

is not

common.

The

distinction

between

hemiparesis or hemiplegia temporo-sphenoidal and a cerebellar lesion been already alluded to. It remains to be

produced by respectively has a

the

said that this symptom in abscess of the temporo-sphenoidal produced by involvement of the adjacent Rolandic area

lobe is

of the cortex former

case

or

by

pressure upon the internal

the onset of the

hemiplegia

may have

patient

enough

comes

point.

arm,

the time

history rarely definite Horsley, in the discussion pointed out the importance of a

under observation the

to determine this

definite and

a

march, affecting in order the opposite side of the face, the the leg. If, however, the hemiplegia is established by the

In the

capsule.

is

Sir V.

Otological Section, also investigation into those forms of sensation represented in the cortex, especially the distinction between two points as such and sense of localisation. He also pointed out that in cases of multiple abscess the second one is often in the parietal at the

careful

lobe,

and that there may then be

side of the

opposite Lastly,

a

rise of

temperature

on

the

on

the

body.

from pressure upon the Illrd nerve, the

pupil

ON INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

side

of

temporal abscess may be dilated and stabile,

a

a

107

valuable

sign. The above is

localising

a very brief summary of the signs which value in abscess in these two situations.

are

of

As has been already stated, in some of the symptoms the presence of double otorrhoea makes it difficult to determine

their significance. It would be a great gain if the aural surgeon double otorrhoea could give us certain indications as to which

ln

ear is the source of intra-cranial abscess ;

seems that the

mischief

which is not

ear

but

presenting

unfortunately

it

the most active

at the time of observation may be the offender in this

Particular respect. The

diagnosis

of abscess may be still further

complicated

by (1) the concomitant presence of meningitis, in which case the distinction could only be made by there being present definite

.localising

Meningitis, propose

and

to take

an

rence of abscess in

Mtroduction

abscess in addition to the

general signs of (2) by the occurrence of encephalitis. I do not up more of your time by discussing the occur-

of

signs

more

unusual

situations, and will end this

to the discussion

by emphasising, when an intraof ear disease is suspected, the value of an Examination of the cerebro-spinal fluid, except in a case where an abscess in the cerebellum is fairly certain, in which case it is safer not to do a lumbar puncture, and of the risk of delay in operating when the diagnosis of an intra-cranial abscess has been arrived at. I should like to ask when a cerebellar abscess cranial complication

secondary to ear disease is present what aPproaching it, whether, if there has been

from ln

the

the

disease after

a

original opening or from occipital region. Lastly, if without evidence of abscess free mastoid

?peration

of

has

a

mastoid

operation,

separate trephine opening

there is

optic neuritis in ear or meningitis, and it persists been done, a decompression

should be carried out.

Mr. Lacy

surface

operation

a

is the best route of

Firth

said:

(i)

Inflammation

of

the

outer

the dura mater and extradural abscess.?In this

c?mplication

of

suppurative

ear-disease

the

collection

of

108

J. MICHELL CLARKE AND MR. LACY FIRTH

DR.

inflammatory material, granulation tissue and pus, is epidural, lying between the surface of the temporal bone and tne dura normalty in contact with that bone. Ihe incidence of the complication is almost doubly as frequent in males as in females. It affects individuals of all ages about equally. The inflammation

causative bone

itself, which

cholesteatoma.

tympanum It is

is

More

most

carious,

necrosed,

the

rarely

involves

often

mucous

or

the

temporal

ulcerated from

membrane of

the

antrum is alone involved.

or

important point that pachymeningitis externa is frequently met with as a complication of acute than The bone disease, when present, usually chronic otitis. an

more

of

extends to the dura, but sometimes the

fistulous tract

from the

path

of infection is

a

cavities to the dura,

passing perhaps periphlebitis of vessels in the bone. Diplococcic infection is the most frequent. In some cases the extra-dural abscess may be secondary to sinus thrombosis, the inflammation passing from the sinus through its outer wall ; but often the reverse is the case, i.e. the extradural abscess is primary, and the thrombosis secondary. It is in the cerebellar fossa that the extension of inflammation is most frequently found, but it arising

ear

from

Sometimes very large may be in the middle fossa, or in both. of For example, the form in these situations. collections pus pus may extend up to the sagittal suture, or backwards to the

torcular, Even cause.

or

downwards to the

retro-pharyngeal The

inflammation or

dura or

may

bulb and into the neck.

penetration of the inner surface for weeks, months

withstand

abscess to its

years if the pus

not the further

jugular

abscesses have been observed from this

partially complications of can

escape sinus

through

disease,

the ear, but if

brain abscess or

meningitis will ensue. Symptoms.?Frequently there are no symptoms of extradural suppuration over and above those of aural and mastoid inflammation. Fever is usually absent. In children fever is commoner than in adults, just as fever is commoner in them also from uncomplicated aural disease or from mastoid disease. Cerebral pressure symptoms

are

usually absent.

There may,-

ON INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

however,

be

IO9

headache, drowsiness, vomiting, slowing of the stiffness of the neck, and even such

Pulse, optic neuritis,

disturbances

crossed

as

More important signs

Present, t?

paresis

troubles.

speech

abscess, though seldom

and tenderness above the ear, due

swelling, pain

are

and

of extradural

temporal bone by signs behind the ear, due to penetration of through the foramen of the mastoid emissary vein. Diagnosis.?The cerebral complications mentioned above, Vlz. drowsiness, vomiting, optic neuritis and stiffness of the neck, do not enable a distinction to be made between this complication and those of brain abscess or A meningitis. very free outflow pus from the ear may awaken suspicion ; but brain abscesses have sometimes discharged through the tympanum, or through h?ny fistula in the squamous portion of the temporal bone. ?^l?m the practical point of view it may be said that if a patient penetration of the squamous

the pus, or similar ^e abscess

has 0r

an extradural

less

Mastoid

^hich

abscess

we

strongly pronounced

may expect him to present indications

present indications

are

of the

for

opening

more

the

up

or, stated in the reverse way, in any case in

process ;

there

portion

of mastoid

suppuration,

Specially if acute otitis media is the primary cause, one is not ^likely to find pachymeningitis externa or extradural abscess, and one should, at the operation, be careful to follow UP any necrotic

or

dural region.

fistulous tract which may pass to the extra-

This consideration brings us to inquire, What are the indicaor signs which suggest that the mastoid process should be

tions

in suppurative ^plored understood by has existed |vhich the tympanic cavitydays. acute

e

otitis ?

acute otitis is meant not

that

a

few

as

A

patient

and membrana

lriflamed, and these parts lnflammation for weeks or In fl

months.

place merely an

otitis

has acute otitis

tympani

may continue in even

let it

In the first

a

are

so

acutely

state of acute

The state of acute

arnrnati?n is obvious on examining the ear with adequate ill uunation through an aural speculum, and comprises membrana tympani, redness opacity of Jelling, the adjacent parts of meatus, with concealment the

and

the

and

of the

110

J. MICHELL CLARKE AND MR. LACY FIRTH

DR.

malleus, and probably with the presence of reflex, with or without a visible perforation of

a

pulsating light

the drum-head.

The indications for

opening up the mastoid and antrum are, The of course, clear if a typical mastoid abscess is present. auricle is then pushed outwards and downwards, the fold or crease between the pinna and mastoid is obliterated, and the skin is tense, swollen and fluctuant. In the absence of the above typical indications for

operation

are

not

so

signs

clear.

of abscess the

We must all have

otitis, especially in children, in which there was not only pain and tenderness over the mastoid, but even swelling there, due no doubt to periostitis, and yet in such seen cases

cases

of acute

recovery has taken

place

conclude, therefore, abscess in the mastoid,

operation. We must periostitis may exist without

without

that mastoid

and may subside under

antiphlogistic

good drainage from the tympanum through either a spontaneous perforation or an opening made by paracentesis. If a perforation is present and inadequate it should be enlarged by paracentesis. But if external mastoid periostitis may subside without opening up the bone there is another form of periostitis which indicates clearly that there is suppuration of the antrum, and that operation is required. I refer to periostitis of the deeper of the meatus. The swelling from this portion auditory narrows the meatus in its deeper part, and the swollen part, which has this special significance, is that on the upper and back part of the deep osseous meatus. This swelling is tne so-called sagging" of the posterior superior meatal wall, that is> swelling of that part of the meatus which lies nearest the antrum. The swelling is really the pointing of an antral treatment if there is

"

abscess, and

a

and in

some cases an

opening

forms there, pus escapes,

fistulous tract is left.

In other

cases

of acute otitis the indication for

operation

the mastoid is the presence of persistent pain, vertig?> tinnitus, vomiting, or nystagmus. The persistence of any one of these symptoms is an indication for operation. on

It must be

admitted, however, in spite of

the

help given by

?N INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

SUch indications

as

decide whether acute otitis.

Ill

those enumerated, that it is often difficult opened up or not in

the mastoid should be

operation required in such cases is not a ifficult one which demands exceptional skill, but obviously patient should be spared operation if that is possible with Safety. The trouble is that a sudden development of cerebral ^ttiptoms may arise in a case of otitis which has been running an alm?st painless course. The important fact remains to be stated that you may wait with more safety for clear indications Mastoid suppuration before operating in young people than The

111

People of middle or advanced age. In middle life the mastoid Pr?cess is more likely to be sclerosed. If a mastoid with a thick c?rtex or a sclerosed cortex suppurates, the suppuration is more fa

ngerous because the pus cannot

so

Surface

easily

make its way to the

and cause periostitis and mastoid abscess. Failing in that direction, the pus is likely, unless a timely ?Peration is performed, to spread inwards through the labyrinth

CS-CaPe ?r

by

other routes, and

tr?ubles. ^

^

give

rise to

dangerous

intra-cranial

With respect then to elderly people, the wisest practice is ?Pen up the mastoid if acute suppurative otitis has continued five or six weeks without distinct signs of abatement, even ?ugh there Perature. ^ ay

mastoid tenderness, and no elevation of Lastly, in influenza and in diabetes it has

is

no

remembered

that

dangerous

mastoid

complications

develop insidiously.

children and young people gainst operation must be the

deciding factors for or tendency of the general and local ^ptoms to increase or decrease from day to day. The *y opening up of the mastoid process is to be regarded as U0 important method of preventive treatment of the int -cranial complications of ear-disease. Infective Lateral Sinus Thrombosis.?This complication rn?re commonly found in connection with chronic than with e disease in the temporal bone, and in the great majority ^ cases the temporal bone itself is affected, not merely the ?~Periosteum of the tympanum and mastoid cells. Very TV,

the

iJ2

DR. J. MICHELL CLARKE AND MR. LACY FIRTH

frequently

there is

the

outer

a

perisinus abscess,

and this is the

cause

of

The presence of pus or granulation tissue on of the sinus naturally favours thrombosis-

the thrombosis.

wall

origin appears to be the spread of thrombi into the sinus from small blood-vessels which pass into it from Another mode of

the

bone.

temporal

having began in the lateral sinus, usually at the knee or in the sigmoid portion, tends to extend in various directions. It may spread backwards against the blood-stream towards the torcular, rarely to the longitudinal sinus, and to the transverse sinus of the opposite side. Extension, againmay occur along the superior or inferior petrosal sinuses, and Thrombosis

through

tnese into the cavernous sinus of the to the

possibly the opposite

side, then the cavernous sinus of

ophthalmic vein, and to Thirdly, the extension

side.

same

the may be with

blood-stream into branches of the sinus, the mastoid emissary vein or the anterior condylar vein, but especially into the jugular bulb and jugular vein, even into the innominate vein, and als? into the facial branch of the

jugular vein. Symptoms.?Cerebral symptoms may arise from the presence and irritation of an inflammatory focus within the skull, through circulatory obstruction in the sinus, and possibly through accompanying meningitis serosa. The cerebro-spin^ fluid is generally increased in amount. Headache is usual diffused or limited to the affected side ; vomiting in the early Course and

stages is also usual. symptom, but in

septicemic

course

In the

severe cases

a

septicsemic cases delirium is running a more pyaemic th^n

consciousness is not altered.

The cerebral symptoms are, as in all aural intra-crani^ more marked in children than in adults. OptlC neuritis is not common in pure sigmoid sinus thrombo?is. The general course of the affection in the organism can be

complications,

chiefly septicaemic rarely a pure form

in character of

one or

The most characteristic occurrence

by

a

of

rigors

sudden fall.

with

a

The

or

chiefly pyaemic,

but it

lS

the other.

sign

of the

pyaemic

form is the

folloWe^

sudden rise of temperature, rigor may last from a quarter

ON INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

113

^alf an hour, or even one to two hours. Sometimes these Tlgors occur once daily, or there maybe two or three days' interval between them, or there may be, on the other hand, two or three ugors in

twenty-four

Successfully rigors

hours.

A

case

dealt with, in which

has been

no

reported, and sixty-five

fewer than

occurred.

The spleen

is usually enlarged, the pulse rises and falls with Metastatic complications occur most temperature. COrnmonlv in the lungs only, much more uncommonly in other Parts as well as in the lungs, and very rarely in other parts and in lungs. The sterno-clavicular and shoulder joints are ^ourite seats of the secondary abscesses, but such may occur 3n the subcutaneous tissue, in other joints, in bursae, and in Muscles. Sometimes these metastatic inflammations do not ln

in suppuration. the

More

kidneys, spleen

rarely

metastases have been found

and liver.

^ere may well be mentioned a clinical type of case to which 0rner has directed attention, in which there is otitic pyaemia

Vlthout

V?ung

sinus

phlebitis.

The

patients

are

usually

children

or

affection is acute, pyaemic deposits occur the bursas and joints, muscles, with absence of such, as a U^e> in the lungs. The prognosis is favourable without

people,

Oration

the

on the

ear

sinus.

In the septicaemic type of sinus thrombosis, as distinguished ^ symptoms are those of an acute, rapidly al septic poisoning or toxaemia. There is high continuous

fat^ ^

er?

delirium,

pulse ; metastatic abscesses characteristic, septic endocarditis, muscular ^ retinitis and retinal hemorrhages, nephritis and Patitis are often present. The spleen is generally enlarged. ^ eath is usifal in a few days. What is the duration and prognosis in cases of sinus ^ 0rrik0s^s which have not been operated upon ? Frequently th Patient lives two to four weeks?in rare cases longer, even ^ Several months. Death results from such effects as general s Caern^a' from pyaemic metastases, especially pyo-pneumotho rax> and from meningitis or brain abscess. The patients may 9 vol. vYv and

not

a

rapid

small

but

^Jtiorrhages,

No. xi6.

DR-

114

and

recover,

MICHELL CLARKE AND MR. LACY FIRTH

J-

sinus be

the

permanently

withou

obliterated

operation. Now

to the

all-important questions of diagnosis and treatment. The diagnosis of the well-marked cases presents no difficulty. There is characteristic fever, splenic tumour, and signs of jugular thrombosis. There is a sign of thrombosis known as Griesinger's. It is the presence of localised swelling and oedema at the posterior border, of the mastoid, in the position of the mastoid emissary vein. As a matter of is more an this indication of an abscess extra-dural fact, sign than of sinus phlebitis. If this swelling is not limited to the small

we

area

come

mentioned, but also

lies

to mastoid disease

then it

points complications

process,

not to either of the

only,

mentioned.

intra-cranial

the mastoid

over

Irritative

or

paralyti?

effects upon the nerves which pass through the condylar foramen or the jugular foramen may give help. The nerves which may be affected are the hypoglossal, spinal accessory, glossopharyngeal and vagus. Their involvement points to an extension of the sinus phlebitis to the foramina mentioned. The septicemic

may resemble typhoid fever, and resemble malaria. Examination of the pysemic type may of blood will, course, assist in the differentiation of these

type

of

of sinus

case

phlebitis

the

maladies. The

of less advanced and less

diagnosis

difficult.

for

There

symptoms of

a

may, blocked sinus

the characteristic said

that

suspicion

one

of

should be

or

vein,

curve.

a

typical no

cases

local

may t>e

signs

?r

sho^

and the fever may not In this connection let it t>e

rigor

and that the

considered

to exclude

example,

well-marked

pyaemia,

In children with serve

pyasmic

be

should

occurrence

raise of

a

decisive indication for

meningitic symptoms meningitis.

a

strong

second

rig?r

exploration-

lumbar puncture

wi^

With respect to adults, the rule should be to open up,^e mastoid and explore the lateral sinus if there is septic ear-disease

present,

or a

recent

history

of

such, and if fever is present of by the presence of soine

continuous type not accounted for other

disease,

e.g.

typhoid

fever,

pneumonia,

influent'

ON INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

br?nchitis

will

very probably Further, in such

Clrcurnstances.

^h pyaemic fever,

felling ^eel

must

never

I cannot

Evinced

The

etc.

tonsillitis,

or

thrombosis

I

well

in

as

cases.

tenderness and1

of mastoid

be considered to contra-indicate

operation.. point. I am. myself delayed operation to the

too

lay

that

exist in such

to

as

cases,

absence

an

form of sinus

septicaemic

be found

115

much stress

have

this

on

^etriment of patients more than once, because there was no tenderness or swelling of the mastoid process, and I may be *einPted to do so again. I have also seen house-surgeons and Petitioners repeatedly fail ecause there

recognise the need for operation pain, heat, swelling nor tenderness

to

has been neither

the mastoid process. ^VersPared exclude to

No trouble

other

possible

must, of course,

or care

of the fever before

sources

bating. The

difficulty of diagnosis is Mastoiditis may be present when

uhsiding a

or

has subsided.

perforation

of the

tructure

In still

drum,

has been previously the time of examination.

Lastly, 611

th

let

^Gre

*s

by

fact that

the

rarer

and

no

cases

there has not

inflammation of that

recognised,

nor

is

recognisable-

exploration is justified and desirable Pr?bability of the presence of septic sinus that a careful exploration of the sinus is not a

me a

increased

the otitis which caused it is

say

?mbosis, and ailgerous procedure. 0

ls

suni up.

media

If in the

(not

^rulent otitis,

there is

accompanied

and^01"6'

non-aural

^

del

at the

there

course

Wfv

6llSe

case

or

in

of acute a

case

purulent

of chronic

sudden rise of temperature, say to 102? by a rigor, with headache and malaise,

causes

are no

for the of

temperature

meningitis

can

or

be

excluded, abscess,

cerebral

up and the sinus

^ildren are exception ^*?h temperature for a fortnight complications. an

a

a

a

symptoms Irias^0^ should be opened

ha^'

of

beginning),

to the

exposed without rule, for they may from acute otitis

under such circumstances the exposed sinus is found Iia elastic one should wait to see the effect of the mastoid

anrl

1

Tl6

DR. J. MICHELL CLARKE AND MR. LACY FIRTH

?operation. will

recover

"high during

it will prove sufficient, and the patient If the temperature remains thrombosis. without the following days, or if a rigor occurs, then the

Most

likely

interior of the sinus must be We must

explored.

consider the treatment of the sinus when

now

detail.

Some authorities state that

yon depressed appearance of the sinus from ?compression, and a benign thrombus in it which is best left undisturbed. I should myself be too doubtful about the non-infective state of the thrombus to leave it undisturbed in further

?exposed may

have

a

The exposure of the sinus in the search The thrombosed part

:in such circumstances. for

possible

thrombosis should be free.

may be low down in the

sigmoid sinus,

between the lower

bend

the sinus itself may be free from jugular bulb, thrombus, and yet the jugular bulb contain septic clot, infected

-and the

or

perhaps through :at

once

tympanic cavity. I may state myself exposed the jugular bulb either

the floor of the

that I have

never

to examine it for thrombus

there.

I content

myself

?down, and passing towards the

jugular

a

or

to

with

remove

exposing

sigmoid sinus lo^v point exposed

the

curette from the lowest

bulb from above.

bulb, but will pass to a point near from clot I have hitherto relied upon the

into it from the

thrombus known to be

The spoon will not enter it. To clear the bulb itself

passing

vein below.

I

a

curette

upwards

consider

jugular syringing through from vein to sinus rather risky, for the dura mig^ give way, and meningitis result. Operations for exposure of the jugular bulb have been specially described by Grunert and Piffl and Voss. A great drawback to those operations is the proximity of the facial nerve. It is not always easy to decide whether there is thrombosis ?of the exposed sinus or not. If present the thrombus may block the lumen of the sinus, or be merely a parietal layer not blocking

The use of a needle and syringe for exploration f?r safer is than ?clot incision, and may well be employed first. ^ it does not yield sufficient information the sinus must be the lumen.

opened*

If the needle shows the sinus to be blocked it must be laid open.

The clot may be

obviously septic

in the middle

freely

park

ON INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

IIJT

apparently ending above and below in healthy clot. SomeSUrgeons leave healthy-looking clot undisturbed, and remove?nly the broken-down portions. This appears to me to be-

cking

too much risk of

a

continuation of

?u cannot be sure of the

If the

thrombosis..

asepticity exploratory needle withdraws healthy blood,

aPpearance and free from odour, we are Possibilities. There may be parietal clot, 111611

septic

of the clot left behind.

normal in.

faced with several not

occluding

the-

In my opinion the mere suspicion of that being the?*ate of affairs does not justify opening the sinus and tying the?

Jugular

vein.

believe

I

parietal clotting not infrequently without opening up the sinus.. en the exploring syringe may draw off blood because theC^?tting is in the jugular bulb only. There are tests for the Presence or absence of this condition?e.g. Whiting's test? they fail to prove the presence or absence of a parietal: ln the bulb. There is only one way of proving the presence* absence of septic clot in the bulb?that is, by exposing and Pening it. jf in a particular case I felt fairly sure from the ?Ccurs in

^ptoms

treat

which

cases

and

that

signs

+-u

trie case as one

recover

the

bulb

was

with thrombosis of the

U*Q T 1

^?re H

i.e. I

nave, of course, repeatedly done this. But some advocate radical procedures; for example, laying open through. curved continuous incision the sinus, jugular bulb, and. vein.

0rt*bosis

the

^he

111

connection with the treatment of sinus.

about which I wish to

^?aturing thrombosis

speak

Some surgeons jugular others exists, only in certain vein.

following

Almost

as

a

slight

^h?ugh ligature

transmission

is the

question

always

tie the vein

of

cases.

facts bear upon the question :? many cases of sinus thrombosis have been

trea^e^ without the ligature Perl'eSSfUlly aPs show advantage from

the

jugular vein,

"U

ma^er

Sllc

I should

open the sigmoid sinus and jugular vein, and clear out: with the curette as well as possible, and drain both,.

]l^ar th

infected,

of

as

with it.

applying

the

Statistics.

ligature,

of the vein closes the main channel for

septic

emboli to the

lungs

and other

parts,.

.Tl8

DR.

J. MICHELL CLARKE AND MR. LACY FIRTH

:it does not close all channels.

After

ligation

fresh infective

material may, and does sometimes, pass to the heart frofl1 ?emissary veins, from the petrosal sinuses, or from the torcular ?end of the lateral sinus.

(3)

The

of

operation

ligature

of the

jugular

takes time,

and makes another wound, usually septic, and leaves a scar. (4) The operation has certain dangers, viz. (1) it has beefl ?quickly followed sometimes by extension of thrombosis into the inferior

(2)

petrosal sinus,

the sudden

stoppage

and thence into the of the flow of blood

cavernous

through

sinus?

the vei11

may lead to congestive oedema and necrosis of the brain. ThlS Js only likely if the other lateral sinus is abnormally narroW-

Further, this danger

cannot result from

ligation

if the vein ?r

already blocked with clot. But many writers haVe tying the vein for non-obliterating thrombosis. my own opinion the patient's best interests will be served^

?sinus is

.advocated In

this main channel of embolic invasion is closed in nearly I would make an exception if the extent of *he

cases.

small, and healthy sinllS

thrombosis in the

sigmoid

wall could be

above and below the diseased

seen

free

bleeding could jugular end of the

sinus

was

portion, aI1^

be established from both the torcular infected

sigmoid by curetting.

I

an^

\vou^ 0

not trust any clot in the sinus which obstructed the free flow blood from both directions. If ligatured at all, the best tii^6

15

ligature is immediately after the diagnosis whether established, by palpation in the neck, or more usu^ .by inspection of the sinus through the opening in the sk^ ^ It seems to me best to resect a portion of the vein to a leV above the facial branch, after dividing that branch, but ^ leave the upper end of the jugular vein long enough to brought to the surface in the upper angle of the skin wound to

place

drainage

the

purposes. DISCUSSION.

Dr. Carey Coombs, after congratulating the Society 0n 'excellence of the two introductory papers, said that a

.review of the autopsy

figures

of the General

t be

i? Hospital would

ON INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

the basis of his remarks.

There

intracranial complications

of middle

fetal.

In these

times,

thirty-four

ear

cases

in which

inflammation had proved

sinus thrombosis

was

found seventeen

abscess in the substance of the brain, or cerebellum, in cases (temporo-sphenoidal lobe nine, cerebellum five,

fifteen k?th temporal ^as

cases

were

Iig

lobe and cerebellum

surface abscess, extra

a

Cases was diffuse

or

one).

sub-dural,

In three cases there and in

This latter

sixteen

only

most often

meningitis usually accompanied by one of the more localised lesions mentioned above ; presumably in some cases meningitis ^ad only occurred subsequently to abscess formation or sinus thrombosis. He had been surprised to find the incidence of Meningitis so small. Testing the matter from another point of "View, he had found that only five out of fifty cases of fatal Meningitis were otitic in origin. The main inference drawn fr?m these figures was that in most cases there was a stage

basic,

and

^Uring

noted.

was

was

which the infective process within the skull remained in its effects, and therefore open to a successful

Realised Surgical

attack.

Meningitis (if

it

With were

regard

indeed

to

successful

possible,

as

treatment

of

has been claimed of

e). early diagnosis would always be the important factor, "^e mentioned rigidity of the neck with tenderness of the sub-

?ccipital

muscles and

polymorphonuclear leucocytosis in the Cerebro-spinal fluid as valuable signs by reason of their early ^Ppearance. He asked two questions : What was the evidence ?n Which it was claimed that such a phenomena as serous Meningitis occurred ? and Was it possible, in the experience Members of the Society, to save lives threatened by a spreadn? Meningitis by early operation ??Mr. Hey Groves pointed that in view of the uncertain diagnosis in many cases Perative exploration of the lateral sinus and cerebrum and erebellum, on the lines advocated by Mr. Percy Dean, was often "

"

disable.?Dr.

^esembled

alt0aS0' ?gether in ?

^

Stack related

a

case

in which the

symptoms

in every way cerebral abscess following mastoid ^?Ur c^eren^: occasi?ns the brain was explored, about

twenty directions, including

temporo-sphenoidal

both

and both frontal lobes.

c.erebella,

No abscess

120

INTRA-CRANIAL COMPLICATIONS OF EAR DISEASE.

found.

presumed, therefore, to be oedemaJ. rarity of intra-cranial lesionswith acute otitis, although frequently there were transient attacks of cerebritis or meningitis clearing up without operation. Probably all cases showing optic neuritis should have a mastoid operation performed, and if improvement did not result, thenlater the dura should be incised. He compared the symptoms of meningitis and those of cerebral abscess, the distinctive points in the latter being the regular, slow, full pulse, loW temperature (in a cerebral abscess there is a rise of temperature on the opposite side of the body), motor paralysis, perhaps with loss of localisation of touch, slow disappearance of the superficial reflexes on one side only, and unilateral optic neuritis with He described a case of cavernous moderate swelling of the disc. sinus thrombosis, which made a good recovery, and mentioned that when vaccine therapy had to be employed in intracranial suppuration the vaccine was generally a compound one. In a case of cerebellar abscess under his care the organisms were a a bacillus, a diplococcus, and the bacillus pyocyaneus ; in the case of meningitis the organisms were a staphylococcus and was

Dr.

The

case

Dr.

pneumococcus.

difficulties that many to

was

O. Symes referred to the

aural

Watson-Williams

remarked

on

the

of intra-cranial infection secondary presented?firstly in determining the

cases

suppuration

existence of intra-cranial

between sinus

lesions, and secondly in differentiating perisinus suppuration, sub-dural or lepto-

or

meningeal abscess,

and abscesses of the cerebrum

and illustrated these

points by citing

these difficulties arose, and

operate

on

from time to time.

notice consisted of those in chronic

purulent

mine which

ear was

patient

was

cerebellum ; in

which

which he had been called to

One group to which he directed where acute complications arose

source

semi-conscious.

most valuable differential

ears.

One had then to deter-

of the intra-cranial

the diffculties in differentiation the

or

cases

cases

otitis in both the

various

complication,

.increased when He believed that one of the

being greatly

diagnostic

aids

was

the presence

of

optic neuritis restricted to or most marked in one disc, and ipso-laterality of the intra-cranial lesion was sometimes

the

differential

diagnosis of swelling in the breast.

121

the only guide as to the side requiring intra-cranial exploration, Mr. A. J. Wright pointed out that it had been estimated that

7 per cent, of the

Neuritis.?Mr.

cases

of

suppurative

ear

disease had

C. H. Walker and Dr. Walker Hall

optic joined in

discussion. REPLY.

In ^th

reply,

Dr. Michell Clarke said that Dr. Coombs's statistics

fewer number of

fairly corresponded in proportionate frequency given by Dr. Logan burner at the discussion in London. He had not had enough Personal experience to allow him to express an opinion as to Serous meningitis. In the cases of diffuse septic meningitis he had seen the issue was lethal. Dr. Stack's case was a good illus*ration of the difficulties of diagnosis in intra-cranial abscess, ^ith regard to optic neuritis, he thought that if an individual Case it was of unequal severity on the two sides that point was more importance in the differential diagnosis than the intensity the swelling. In reply to Dr. Edgeworth, the plantar reflex 111 an uncomplicated lesion of a lateral lobe of the cerebellum ^v?uld be of the flexor type. Dr. Wright's statement that optic Neuritis was present in seven per cent, of cases of middle ear a

cases

of affections considered to those

SuPpuration

brought

^here

ahout

was one

out in the

was no

of the

points

which he had

discussion, and

doubt that the

chronic otorrhoea.

public

was were

of

hoped would be great importance,

still much too careless