Part 61 (1/2)

2. A stricture of the Eustachian tube may be so great as to prevent entrance of the bougie.

=Dangers.= (_a_) Surgical emphysema. If the mucous membrane be lacerated by the bougie, air may be forced into the subcutaneous tissues on inflation, after its withdrawal. In some cases the surgical emphysema is so considerable as to involve the side of the neck and face, and indeed has been known to necessitate the performance of laryngotomy.

The best treatment is to make the patient suck ice and to forbid all attempts at blowing the nose and coughing. Sometimes it is also necessary to scarify the pharynx and soft palate with a small bistoury.

Recovery may be hastened by gentle ma.s.sage of the neck and face.

Inflation should not be attempted again for at least a week.

(_b_) The bougie may be pushed in too far and cause injury to the contents of the tympanic cavity.

(_c_) The tip of the bougie may break off whilst in the Eustachian tube.

With a gum-elastic bougie this is very rare, but it is more likely to occur if the brittle celluloid bougies are used. To prevent this unfortunate disaster the bougie should be carefully examined before pa.s.sing it, to see that it is not cracked nor broken. If such an accident does happen it is wiser to do nothing, because as a rule the fragment is afterwards expelled spontaneously.

=Results.= If the obstruction be fairly recent and limited to the pharyngeal end of the Eustachian tube, excellent results may be obtained by using either the simple bougie or the catgut variety moistened with a 5% solution of silver nitrate.

Owing to the general thickening of the tube, there is a marked tendency for further stricture to take place in the more chronic cases, even if a temporary improvement is obtained, and for this reason the use of the bougie is seldom to be recommended.

WAs.h.i.+NG OUT THE TYMPANIC CAVITY THROUGH THE EUSTACHIAN TUBE

=Indications.= (i) In chronic middle-ear suppuration in which the perforation is situated in the anterior inferior quadrant and the continuance of the otorrha is apparently due to the secretion not being able to drain from the tympanic cavity. This method may be employed to effect drainage and in order to cleanse the tympanic cavity thoroughly before the instillation of medicated drops. In these cases the floor of the tympanic cavity is usually at a considerable depth beneath the lower limit of the membrane (Fig. 186).

(ii) In order to remove a small foreign body lying on the floor of the tympanic cavity which cannot be expelled by syringing. The operation is only tentative and is seldom successful.

=Contra-indications.= (i) If there be acute middle-ear suppuration; (ii) if the perforation be very small, as there will be a considerable risk of the fluid being driven into the mastoid antrum and further infecting it.

=Technique.= A catheter of wide calibre is pa.s.sed in the ordinary manner. Inflation is practised to see if it is in the right position.

The left hand fixes the outer extremity of the catheter at its entrance within the nose and keeps it in position. The patient inclines the head over to the affected side and holds a receiver beneath the ear. A small bra.s.s syringe whose nozzle accurately fits the outer extremity of the catheter is used. Slight force may be required during the act of syringing, but must not be sufficient to cause pain within the ear. A certain amount of fluid always escapes into the throat although the catheter is in its right position, and this may set up an attack of retching and coughing. To avoid this the patient should incline his head slightly forward as well as to the affected side and breathe gently with the mouth open. If the manipulation be successful the fluid will trickle out of the external meatus.

A foreign body is rarely expelled by this method, as the force of fluid syringed into the Eustachian tube is seldom sufficient, and it is not wise to use too great pressure. In order to expel all the fluid from the tympanic cavity, the ear is afterwards inflated by Politzer's method, and at the same time the fluid is mopped out of the ear by means of pledgets of cotton-wool.

=Results.= If the continuance of the middle-ear suppuration has been chiefly due to the retention of the purulent secretion in the lower part of the tympanic cavity, this method of treatment is frequently most satisfactory. In other cases no benefit is obtained owing to the suppuration being due to other causes.

=Dangers.= The chief danger is the infection of the mastoid cells.

CHAPTER V

OPERATIONS UPON THE MASTOID PROCESS: WILDE'S INCISION AND SCHWARTZE'S OPERATION

With few exceptions the conditions requiring operative procedures on the mastoid process are the result of some suppurative lesion which has originated within the tympanic cavity.

The object of such operations is to arrest or eradicate the disease which, by further extension through the bony walls of the temporal bone, might eventually cause death by giving rise to some suppurative intracranial complication.

For their successful performance a knowledge of the anatomical relations.h.i.+ps of the mastoid process is essential. It is sufficient here to remind the reader of the main surgical points in this connexion (Fig.

215).

SURGICAL ANATOMY OF THE MASTOID AREA