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The ear is one of the organs of the body most susceptible to disease, chiefly perhaps from its position; for instance, the eustachian tubes leading from the pharynx to the tympanic cavities, give ready access for invading bacteria from the throat.
The external ear is liable to injury, in congenital deformities and to a special type of eczema. In a large number of cases the latter tronble is secondary to suppuration in the tympanic cavity, for the constant triolcling away of the pus thence, over fhe lining of the external auditory meatut, irritates and inflames the latter so that the passage becomes blocked by inflamtnatory swelling, and, unless quiclely relieved, serious complications may ensue.
As in other regions of the body, infection of the external ear may result in the production of a boil or boils, which cause severe pain because the acute inflammation involves tissues that are closely bound dovn to and have very little loose material between themselves and the underlying bone; it often amounts to real agony, which is only relieved by its rupture and discharge of pus. These boils can sometimes be aborted, but, when once fairly developed, they generally require lancing and subsequent antiseptic treatment. They are often due to infection by the purulent discharge from suppuration in the inner ear, and in these cases, when the urgent symtoms have been relieved. The treatment is directed to the original cause.
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This diagram is in the nature of a physiological conspectus of the sequence of operations in the fact of hearing. Vibrations of the ear drum are communicated by the ossicles to the fluid in the cochlea and there translated into nerve impulses.
Inner Ear Disease
Catarrhal affections of the inner ear are extremely common, and, though originating in several different ways, invariably result in deafness if not treated promptly and skilfully. The nasal passages (nostrils) open behind into the pharynx, and it is with this latter region also that the Eustachian tubes directly, and thereforo the tympanic cavities indirectly, communicate. Again, it should be realized that the mucous membrane lining all these passages and chambers is continuous so that should an infection originate either in the nasal or pharyngeal regions, it may, and often does, spread along the mucous membrane in any direction to which that structure extends.
The most obvious illustration is that offered by the common cold an infection by microorganisms of ths nasal mucous membrane. In many cases there develops a varying aural discomfort, followed by deafness, and this may develop into actual ear infection.
When acute catarrhal inflammation develops in the tympanic cavity from the infected Eustachian tube, the lining mucous membrane of the tube becomes swollen by catarrhal inflammation, and its calibre, never very capacious, becomes reduced to such an extent that contplete, or almost comnlete, blockage occurs. Before very long the air in the tympanic cavity becomes more and more rarefied, with the result that the drum becomes strained and is gradually pushed inwards or retracted owing to the greater external pressure on its outer surface.
When the inflammation dies down resolution occurs, the swelling of the tubal lining diminishes and the tube is open again, so that the prossure of the tympanic air once more rises to that of the atmosphere.
Repeated attacks of acute catarrh inevitably end, however, in chronic pathological changes that may lead to serious disablement. To prevent recurrence the general resistance to infection must be strengthened and the ear passages maintained in a healthy condition. Expert treatment is generally indicated.
A very common cause of inflammation in the tympanic cavity is an infection spreading from septic tonsils and the presence of adenoids, especially in children, but also seen very frequently in adult life. Unfortunately the infection is not so mild as that resulting in the ordinary cold, but may be influenzal or streptococcal in character; it is in these cases of more virulent infection that the inner chambers become invaded, with inflammation of the mastoid antrum and cells and the danger of still more serious complications such as meningitis, abseess of brain, etc.
EAR: CONSEQUENCES OF CHRONIC CATARRH Results of chronic catarrh are depicted here; the drum is thickened, and, therefore, less elastic and less sensitive to the sound waves; and adhesions have formed between the ossicles and between these and adjoining parts interfering with the transfer of motion to the inner ear.
Foreign Bodies
Many kinds find their way into the external auditory meatus. Of these the commonest is wax (q.v.), which, although the physiological secretion of the ceruminous glands, may rightly be classed as a foreign body when it gives rise to pathological symptoms. It should be removed by syringing as described below.
Other foreign bodies that find their way into the external auditory meatus include beans, marbles, hooks and eyes and insects.
The auditory canal, or outer ear, consists of a curved tube composed partly of gristle and partly of bone. The membrana tympani, or ear drum, divides it from the middle ear and, in order to protect this delicate membrane, the canal is furnished with wax-secreting glands and with short hairs at the external opening.
Like an ear trumpet, the auditory canal is a tube for conveying souud. It is through the auditory canal that the vibrations of the air are conveyed to our hearing apparatus.
The canal is about an inch and a quarter long in the adult; in children it is very slort. It does not lead straight into the head, but is curved like the letter "S," travelling first forwards and slightly upwards, then inwards and backwards, and then inwards, forwards and downwards. It is composed partly of cartilage or gristle and partly of bone. The cartilaginous portion is a funnel-like continuation. inwards of the cartilage of the external ear, and it is continuons with the bony portion; this leads into the cavity in the skull in which is housed the delicatc mechanism for interpreting sound.
The whole canal is lined by a continuation inwards of the skin of the body; across the inner end is stretched obliquely the fine membrane known as the drum of the ear.
At the external opening of the canal are some short, crisp hairs, and in the cartilaginous portion are glands which form wax. The hairs and the wax protect the delicate drum from dust, or from small insects which might otherwise find their way in. An excess of wax in the auditory canal is a common cause of deafness, as it forms a plug which interferes with the conduction of sound vibrations to the ear drum.
Wax and foreign bodies are best removed by syringing with warm water. The ordinary india rubber enema syringe is quite suitable for the purpose. If a glass syringe is used the nozzle should be covered by a piece of rubber tubing. Pull the auricle or external ear backwards and upwards, and do not introduce the nozzle into the opening of the ear; but keep it just outside lest it block the opening and set up a dangerous air pressure. In this position the water will flow freely into the ear, and, getting behind the obstructing body, will force it out. The addition of a small piece of ordinary soap to the water assists. Syringing must be done gently.
Sometimes the wax is so hard that it will not come away at the first attempt. When this is the case it is wise to introduce a few softening drops into the ear for a day or two before attempting a second washing. For this purpose a solution of bicarbonate of soda is very useful; it should be used in the strength of one and a half grains to eacb drachm of water, and about half a teaspoonful of this should be poured into the ear daily. Almond oil and olive oil are also used for the purpose. If the foreign body is a pea or bean, water should not on any account be put into the ear prior to its being seen by a doctor. Water causes such objects to swell, and increases the difficulty of getting them out.
(1) Deafness may be due to an accumulation of wax in the outer ear. To straighten out the curves of the auditory passage when examining or syringing, the ear is drawn upwards and backwards. (2) The nozzle of the syringe is pointed towards the back part of the canal, but it must not be actually pushed in. The stream of water from the syringe must be gentle.
Inflammation of the auditory canal is not uncommon. Small pimples, boils, and abscesses sometimes occur just witltin the external opening. They are very painful and are apt to recur, and thn treatment may be troublesome. Hot fomentations may relieve the pain of these suppurations, and anodyne drops are also usedy for the purpose surgical interference may be necessary.
Eczema of the auricle and outer portion of the auditory canal is not uncommon, and may be the cause of a slight chronic discharge from the canal.
The external opening of the ear shonkl invariably be kept clean and free from dust and dirt, which are harbourers of germs that produce inflammation and suppuration. In cleansing the ear, care should he taken not to introduoe any hard-pointed instrument inside the external opening.
Earache may be caused by affections of the ear itself, or be of the nature of referred pain from trouble in some neighbonring structure such as the tonsils or teeth.
In the external ear the most common and also the most severe type of pain is caused by furunculosis, or boils, in the external auditory meatus, for here the lining tissues are closely bound down to the bone beneath, so that as the pustule develops there is little room for expansion, and the tension therefore becomes proportionately greater. Relief of tension, either by an artificial incision or by spontaneous rupture, is quickly followed by amelioration of the pain. Cerumen, or wax, when it has accumulated for a long time in the external auditory meatus and become; hard and impacted, may give rise to discomfort amounting to pain. Cancer involving the external ear causes severe pain during its later stages.
Any acute inflamxnation of the tympanic membrane causes pain that varies in intensity, but is specially severe when that membrane is swollen and bulging owing to suppuration in the tympanic cavity.
Relief of earache may be spontanceus or artificial. When the tension due to the inflammatory swelling and ever-increasing collection of fluid, generally purulent, has reached the breaking-strain of the tissues involved, the resistance of the latter is so weakened that they give way and rupture, the fluid escapes, and tension, and therefore pain, is at once relieved.
It is however, considered unwise to allow the tension to advance to the point of rupture, because of the danger of the inflammation extending into the deeper parts and the greater injury to the drum and other parts caused by prolonged acute inflammation and spontaneous rupture. When, therefor. the surgeon deems it wise, he incises the abscess and relieves the tension. If there is definite evidence of spread of the inflammation to the deeper parts a "mastoid" operation will be required. In most cases, taken in time, the operation consists only of a small incision in the drum to allow the pus to escape.
During the earlier stages of inflammation heat, in the form of poultices, or hot lotions; or even plain water, should be applied. Dry heat may be applied by making a little flannel bag and filling it with common salt which has been heated on a shovel, or by boiling a large potato and wrapping it in flannel. Either of these will retain heat for a considerable time. Some cases of earache are relieved by dropping a little warmed almond oil or warm water into the ear. Medical advice should be sought with out delay in all cases where severe earache develops in young children and young adults.
EARACHE: USE OF OIL Earache may be due to hard wax pressing upon the drum. To relieve this a few drops of oil, warmed by first heating a teaspoon over a candle fiame, should be poured into the ear.
Heat in any form tends to relieve earache, and the method shown above is the simplest way to apply it. A little hot water, not too hot, is poured into a teaspoon, and from here is trickled into the affected ear.
Causes, Complications and Lines of Treatment
Purulent discharge from the ear is a condition requiring immediate skilled attention because of the serious comptications that may follow spread of infection to other parts of the organ and perhaps to the brain itself. The symptoms of tympanic suppuration, both acute and chronic are described in detail here, and the measures to be adopted to mitigate pain pending surgical relief are indicated.
Discharge from the ear, or aural suppuration, means in the great majority of cases a purulent dischare from the tympanic cavity. In some few cases the discharge is from the meatus of the ear only, as the result of a boil situated in the skin of the Far passage, technically described as furuncle of the external auditory meatus.
Tympanic suppuration may be of the acute or of the chronic form.
When suppuration in the middle ear has perforated the drum, a considerable opening may occur and is most commonly situated in the lower and back part of the membrane; it maybe much larger than that shown.
The possible causes of acute tympanic middle ear suppuration are many. By far the most important are the acute specitic fevers-scarlet fever, measles, influenza, and diphtheria, in the course of which the middle ear is very liable to ascending infection from the pharynx and naso-pharynx. Any septic inflammation of the nose, the common cold, an adenoid (tonsil) infection, may be a cause. Other occasional causes are fracture of the base of the skull, the effect of a foreign body in the external auditory meatus and direct external injury to the ear.
The predominant symptom in the early stage is pain, sudden in onset and usually of a rapidly increasing severity, with sharp neuralgic twinges involving the side of the head and the jaws. The pain usually ceases suddenly when the drum ruptures. There is alway some deafness and usually subjective noises and giddiness The temperature rises to100 or to 103° F., or even higher, and a shivering fit may occur. There is general malaise and sometimes prostration. In young childrn the condition may closely resemble meningitis. Sooner or later, in most cases, the drum perforates, discharge from the ear appears and all the symptoms consequently become much reduced in intensity.
In the diagnosis of acute middle ear suppuration it is important, especially in the early stage, before the drum has perforated not to confuse the condition with othr aural diseases: for instance, polypus of the ear, boil of the meatus, exostosis or bony tumour of the ear passage and simple inflammation of the drum surface.
Complications of various degrees of severity may at any time arise in connextion with any case of acute middle ear suppuration. In favourable cases disease remains limited to the tympanic cavity the discharge ceases in a few days, the membrane heals up, and there is eventually restoration of perfecy hearing. ln less favourable cases the tvmhanic disease becomes chronic, and passes into the condition known as chronic middle ear suppuration.
The possible complications which constitute the real danger of this disease depend for, their existence on the spread of infection from the middle ear cavity to other parts. Infection may spread to the mastoid antrum and cells, causing the dangerous condition known as mastoiditis; to the meninges, c;ausing meningitis; to the great veins of the brain, causing clotting in the venous channels; to the labyrinth or organ of equilibrium, causing labyrinthitis; or even into the brain itself, causing the frequently fatal complication known as abscess of the brain.
Complications of a less serious nature that sometimes occur are fixation of the littte bones of the ear, infection of lymphatic glands in the neck, especially in children, and boils in the external auditory meatus.
lt is fortunate that complications of a serious kind are often heralded by certain danger signals which it is very important to recognize. Such signals, however. can only be recognized and interpreted by an expert. The more obvious ones are shivering fits, giddiness, headache and stiffnrss of the neck.
Above: considerable collection of pus in the ear, bulging out the drum towards the external ear passage; this causes much pain. Below: the drum, or tympanic membrane, has burst allowing the escape of the pent-up matter; this brings instant relief from pain.
Early treatment is of the first importance, and should always be carried out by a medical man. At the earliest stage harm can never be done by the application of hot poultices to the ear, renewed at frequent intervals, and by the instillation of warm olive oil or glycerin drops. A small quantity of olive oil should be warmed in a teaspoon over a small flame, transferred to an unheated spoon, and thence three or four drops poured into the ear, the patient lying down with his head on one side, the bad ear being uppermost. After the instillation of the drops, the head should be kept quite still for five or ten minutes, and then a small wad of sterile cotton wool very lightly inserted into the passage of the ear.
The mouth and teeth should be kept scrupulously clean. Warmth, rest in bed, light diet and regulation of the bowels are essential as accessory measures.
At a later stage, when pain is probably increasing in severity the temperature is rising and the drum bulging, the treatment is always surgical. That is to say, at this stage a free incision of the drum is necessary. No operation in aural surgery is more effectual than incision of the drum membrane (paracentesis tympani) if carried out with skill and at the right moment.
Chronic middle ear suppuration is always the result of the acute form. The disease in the acute phase fails to resolve or to respond to treatment, and gradually lingers on into a chronic condition. Sometimes this is due to neglect of proper treatment in the early stages.
The symptoms resemble those of the acute form. Discharge from the ear is often profuse, and may be blood-stained. If there is associated bone decay the discharge may be of offensive odour. Subjective noises and some giddiness are usually present. All symptoms are less severe in the chronic forms. Pain is usually absent, and general symptoms like malaise, sickness and rise of temperature are also often slight or absent.
In old-standing cases the drum often undergoes extensive destruction, and may indeed become totally destroyed. An aural polypus sometimes develops. Decay of surrounding bone tends to occur, also decay of one or other of the little bones of the tympanum. In all cases hearing tends to deteriorate.
At any period during the course of a chronic middle ear suppuration the risk of serious complication, which may threaten life, is a possible. Hence the importance of every patient submitting himself to expert examination. The risk is always greater in children.
EAR SUPPURATION: HOW A POLYPUS MAY ARISE From a diseased portion of bone due to suppuration in the middle ear a polypus may arise. This has usually a slender pedicle, or stalk, and the expanded portion pushes out through the ear passage, reaching sometimes as far as the external orifice.
The danger is least in cases of short duration when bone decay is not present, and where the discharge is unimpeded. Since the majority of discharaing ears have been originally infected from the nose and throat, it is an essential step in the treatment of all cases to render the nose and throat a a clean and aseptic as possible by the use of gargle spray and toothbrush. Nasal obstruction should be rectified. Adenoids and infected tonsils in children should be removed.
The discharge should be carefully mopped away with cotton wool on the end of a thin probe, three times a day after which warm drops of carbolic acid and glycerin should be inserted. A 10% volume solution of hydrogen peroxide may be gently instilled from a pipette. It helps to remove debris. Syringing of the ear should only be undertaken by skilled hands, unskilled syringing may do great harm. All treatment, even if carried out at home, should be under the direction and occasional supervision of a medical man. If the condition has not cleared up after a period of four to six weeks, some form of mastoid operation will usually have to be considered.
Danger signs occurring in the course of the chronic form of the disease are: recurrence of an aural polypus after it has been removed; presence of dead bone in the ear; severe headache: giddiness; the onset of a peculiar movement of the eyes known as nystagmus; pain and tenderness behind the ear: facial paralyis; and shivering fit.
Some Popular Misconceptions
Discharge from the ear bears such a vital relation to health that it is of the first importance for those who suffer from this dangerous disease and for those who have to do with its treatment to have right ideas on the subject.
A discharge from the ear, whether acute, subacute or chronic is always accompanied by risks, as noted above. Whenever an ear discharge exists it should always be the aim to arrest the discharge as soon as possible.
There is an old idea that as long as the ear continues to discharge in a regular manner all is well, while the event to be feared is a cessation of the discharge. Nothing could be farther from the truth.
Generally speaking, the longer an aural discharge lasts, the greater the risk becomes and the nearer draws the chance of a dangerous oomplication.