By A. Mitka, l r.c.p L.u.c.s. (Edin.)> Surgeon, Kashmir State Hospital and Chief Medical Officer, Kashmir, ,

Chronic discharge from the ear should always be looked upon with suspicion, and when with it the patient has high fever, great pain, or any brain symptom the duty of the surgeon ?




is clear. Leeches and syringing through external meatus and other local measures usually prove useless and much useful time is lost by delaying the opening of the mastoid and providing free drainage. I have treated many cases with success and I take up a typical one recently treated.

Nehaloo, a sepoy in R. S. Regiment of the Kashmir Army, was admitted into the military hospital on 7th September 1895 Condition on admission.?There was considerable muco-purulent discharge from the right On examination the ear with loss of hearing. membrana tympani was found perforated. General health low. A great deal of emaciation. No appetite. The morning temperature 101 and the evening 103. There is an cedematous swelling behind the ear. tender on pressure, but no fluctuation could be detected. There is headache, occasional vomiting, but no optic neuritis,no rigor. The patient has slight giddiness and complains of of tightness in the head. The present a sense complaint is an old one. The patient had syphil is live years ago and occasionally suffers from rheumatism.

Treatment.?Syringing with antiseptic lotion and insufflation with iodoform and boracic acid, hot fomentation over the mastoid, and a tonic. No visible effect on temperature after a week's treatment. The patient began to get gradually more emaciated. Temperature varied between 101 and 103. Six leeches were applied behind the ear,?no improvement. Headache began to increase. Drowsiness commenced. On the loth day the following operation was done:?Under chloroform anaesthesia an incision was made from the base to the apex of the mastoid process half an inch behind the auricle down to the was found bone. The bone on examination unaltered. The incision was then converted into a T, and a trephine with | in. crown wa? applied immediately behind the auricle on a level with the external auditory meatus. The cleansed. There was cells were thoroughly some haemorrhage which was however easily controlled. Dressings used were zinco-cyanide of mercury gauze steeped in carbolic lotion and dusted over with iodoform. Ear was frequently syringed with perchloride of mercury lotion. The discharge gradually stopped, the wound healed rapidly, temperature fell to normal on the fourth day after the operation, with slight exacerbation in the evening for another six days, after which there was uninterrupted recovery. The patient was given by the mouth mercury and iodide of potash and also bynin emulsion. After five weeks the patient left the hospital and joined his regiment a healthy man, and richer in weight by two stones. For the diagnosis and treatment of chronic discharge as a result of otitis media I give the following hints. The principle in treatment should be to secure



free drainage. If it can be secured through the meatus well and good, if not, go behind the ear. Chronic discharge from the ear, if purulent, is generally from middle ear, may be due to (a> chronic suppuration and inflammation, (b) polypus, (c) granulation, (d) caries of malleus and incus, (e) caries of the temporal bone, (f) diseases of the mastoid antrum, (g) cholesteatoma, (/a) diseases of the naso-pharynx, (i) constitutional diseases, tuberculosis, diabetes, syphilis, JB right's disease, anaemia. If there is swelling behind the ear and pain over the mastoid then it may be mastoid periostitis or sub-periosteal mastoid abscess, and if with it there is deep throbbing pain and typhoidal symptoms, suspect internal mastoiditis. If the pain is more or less generalized there is antral suppuration, and in such a case if there are cerebral symptoms there is lepto-meningitis, and then if there is rigor or well-marked oscillation of the temperature there is pysemia. Temperature is a great guide to diagnosis. If continuously high, then suppuration of antrum ; if with great headache, then extradural abscess if vomiting and delirium, then meningitis. If temperature shows marked oscillation, and if rigor is present and also distension of retinal vessels, then suspect thrombo-phlebitis of the lateral sinus. For treatment: (1) In simple cases frequently syringe with an antiseptic solution,?a few drops of methylated spirit instilled into the ear. After syringing dry the meatus, and insufflate a powder composed of four parts of boracic acid and one of iodoform.

(2) If there is swelling over the mastoid behind the ear try hot fomentation, and a few leeches. If these do not relieve and if there is pain, redness and oedema, make a free incision over the bone. If the

periosteum is loose without any the mastoid cells by a small gouge. The curette and the bur, or the bur and a dental engine have been recently recommended. I have only tried gouge and a mallet. Cleanse thoroughly and insert a few shreds of silk for drainage. Never direct your instrument backwards or you might wound the lateral sinus. (3)

opening, open

hard, and if there are sympshowing suppuration, a small trephine Q\ in. crown) should be applied.


If the bone is

toms or

If there are symptoms of lepto-menincerebral abscess, such as violent headgitis ache, vomiting, unconsciousness and subsequently retraction of neck, optic neuritis, &c., prognosis is very unfavourable and the only cure lies in trephining by a careful localization of the seat of abscess, which is no doubt often a very difficult matter. Even in a case of cerebral abscess with purulent ear discharge, first open the




Otitis Media - Trephining.

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