Part 62 (1/2)

The operations which will be considered are:--

1. Wilde's incision.

2. Opening of the mastoid process and antrum.

3. The complete or radical mastoid operation.

Although definite indications for the above operations will be given, it must be remembered that in many cases the extent of the operation will depend very largely on the pathological condition found during the course of the operation itself, as frequently the clinical symptoms are not sufficient to determine beforehand what operation is indicated.

In comparing the simple opening of the mastoid cells and antrum with that of the complete or radical operation, the fundamental difference is that in the former the tympanic cavity and its contents are not interfered with, whereas in the complete operation the middle ear, antrum, and mastoid cells are converted into one large cavity. In consequence, complete recovery of hearing may take place in the former case; in the latter, however, this is not possible.

Although these operations, especially in the more acute conditions, are performed from the point of view of saving the life of the patient, due regard must also be given to the preservation or restoration of the hearing power, if this indeed is possible. If the hearing power be very poor, that is, if conversation cannot be heard more than 12 feet off, and especially if the deafness be partially due to changes having already taken place within the labyrinth, then the complete operation is to be preferred if it be doubtful whether Schwartze's operation will be sufficient to eradicate the disease. If, on the other hand, the hearing power of the affected ear be fairly good, and with this there is deafness of the opposite side, then, unless it is absolutely essential that the complete operation should be performed, an attempt should be made to effect a cure by the simpler operation, provided it is first explained to the patient that it may perhaps be necessary to perform the complete operation afterwards.

WILDE'S INCISION

In cases of acute inflammation of the mastoid process or of a subperiosteal abscess lying over it, Wilde made a post-aural incision, incising the tissues down to the bone. The indications for doing this are now considered to be very few, but it must be remembered that in Wilde's day the mastoid operation had not been developed.

=Indications.= (i) In infants it is sometimes justifiable, as the pus may have escaped to the surface of the mastoid process either through the squamo-mastoid suture or along the posterior wall of the auditory ca.n.a.l, between the periosteum and bone, without there being any actual disease of the bone.

(ii) As a temporary measure, to permit of drainage of a subperiosteal abscess, if the operation on the mastoid process cannot be performed for twenty-four hours or more.

(iii) In acute middle-ear suppuration a free incision down to the bone may relieve the pain if there are symptoms of periost.i.tis of the mastoid process; it is, however, rarely necessary.

=Contra-indications.= In older children and adults (with the above exceptions) this operation is not sufficient, as the periost.i.tis or subperiosteal abscess over the mastoid process is secondary to underlying bone disease which can only be eradicated by an operation on the mastoid process itself. Although healing may apparently take place, fistulae or other evidences of mastoid disease almost invariably occur afterwards.

=Operation.= In an infant a general anaesthetic is not necessary, but in an adult gas anaesthesia is advisable. The mastoid region is surgically cleansed; the auricle is pulled forward and a free incision is carried down to the bone, in a curved direction downwards over the mastoid process. Originally Wilde made a vertical incision; but it is better, if possible, that the incision should be the same as would be made in performing the mastoid operation, which indeed will probably have to be carried out afterwards. After the haemorrhage has ceased and the purulent contents of the abscess, if present, have drained away, fomentations should be applied and changed frequently during the first twenty-four hours. After this a simple dry dressing is sufficient.

=Results.= Except in the case of tiny infants, this procedure is seldom successful in curing the condition, and must be considered as only a temporary measure.

SCHWARTZE'S OPERATION

(Opening of the mastoid process and antrum)

=Indications.= (a) _In acute middle-ear suppuration._ (i) If, in spite of free drainage, earache, pyrexia, and tenderness over the _body_ of the mastoid do not abate within three days. This is all the more urgent if the condition is the result of scarlet fever or influenza, as in these cases the disease may spread with extreme rapidity.

(ii) If there be an obvious abscess over the mastoid process; except in infants, in whom Wilde's incision may be attempted as a tentative measure, although it is not recommended.

(iii) If there be symptoms of meningeal irritation.

(iv) If a profuse otorrha has continued for over four weeks and is accompanied by sagging downwards of the upper posterior wall of the external meatus, a definite sign that the antrum is involved.

(v) If a profuse otorrha has continued for over eight weeks, with no sign of abatement, even although the temperature may be normal and although there may be no symptoms of inflammation of the mastoid process. The continuance of the otorrha is presumably due to acc.u.mulation of pus in a large antral cavity. The object of the operation is to permit of free drainage and to prevent involvement of the mastoid process itself. The question of operation, however, must be considered very carefully. There is no doubt that in many cases conservative measures may effect a cure even although the suppuration has already existed for many months.

(_b_) _In chronic middle-ear suppuration._ Although the complete mastoid operation is usually indicated, yet the simple opening of the mastoid antrum may be advised under the following conditions, provided there are no symptoms of inflammation of the mastoid process nor signs of disease of the bony walls of the tympanic cavity:--

(i) If the perforation, however large, be surrounded by a rim of tympanic membrane (showing that there is no disease of its bony margins), and if the malleus be not adherent to the inner wall of the tympanic cavity.

(ii) If the hearing be good, that is, if speech is heard farther off than 12 feet, especially if the other ear (from whatever cause) be quite deaf.

Politzer, among others, still maintains that there is frequently no communication between the affected mastoid cells and the antrum if the mastoid abscess is the result of acute middle-ear suppuration. For this reason he considers that the antral cavity should only be opened if there be definite evidence of bone disease between the abscess cavity and the antrum, or if symptoms of extra-dural abscess or some intracranial complication be present. It is, however, difficult to believe that some communication, however microscopic, does not always exist between the antrum and the mastoid cells, seeing that the latter originally developed as outgrowths from the antrum itself, and must have become infected by direct extension from it. At the same time there is no doubt that complete recovery takes place in a certain number of cases in which the antrum has not been opened.