Part 66 (2/2)

In order to keep the grafts in position, Drew has suggested laying the graft on sterilized gold-beater's skin, and in this way applying it to the interior of the mastoid cavity.

More recently, Stoddart Barr of Glasgow has introduced an ingenious method of getting the grafts into position. The graft is manipulated over the end of a suitably-bent gla.s.s tube, having attached to the other end a piece of rubber tubing with a gla.s.s mouthpiece or small rubber bag. The graft at the end of the tube is pa.s.sed through a wide speculum to the inner wall of the tympanum, when, by blowing air through the tube, the graft is spread out over the inner surface, including the tympanic walls, aditus, and antrum.

AFTER-TREATMENT OF THE CASE

_If the posterior wound has been closed._ Provided the temperature keeps normal and there be no pain and no head symptoms, the first dressing need not take place until the fifth or sixth day. By this time the edges of the skin incision have usually united, so that the st.i.tches can be removed, although occasionally the wound may have to be opened up to permit of drainage on account of septic infection. The withdrawal of the gauze from the auditory ca.n.a.l may cause considerable pain, which, however, can be prevented by continuous irrigation of the ear before and during its removal (see p. 315).

After the gauze has been removed, the ear is mopped out with pledgets of cotton-wool. To relieve the pain a few drops of a sterilized 1% solution of cocaine may be instilled and left within the ear for a few minutes.

Under good illumination, the largest possible speculum is inserted into the meatal orifice. The cocaine solution is mopped out, and the cavity dried, in order that careful inspection of the deeper parts may be made.

The chief point is to see that the flaps are in position. There may be slight oozing from the surface of the wound, but as a rule the bone appears almost white, owing to the fact that granulations have not yet begun to form. The wound is then packed gently and evenly with gauze and the ear protected again with an external dressing and bandage.

Until the first dressing has taken place, the patient should be kept in bed. After this, provided the condition be satisfactory, he may be allowed to get up for a few hours every day, the period being gradually increased; by the tenth day or so he is practically well. In an uncomplicated case there is seldom any shock or discomfort after the operation, so that frequently the patient is anxious to be up and about even before the first dressing has been performed. It is wiser, however, to insist on rest for the first few days.

The subsequent dressings should be done every second or third day, depending on the condition found. If the wound cavity be clean, and if there be no odour, it is sufficient to irrigate it with a simple saline or boric lotion. Granulations begin to cover the bone about the tenth day, when there may be some purulent discharge necessitating daily dressings. To keep the parts sweet, an ear-bath of hydrogen peroxide (10 vols. %) may be given, the ear being subsequently irrigated with a 1 in 5,000 solution of biniodide of mercury.

Provided the patient be doing well there should be no temperature, pain, nor headaches. If any of these symptoms occur, or if the patient feels ill, or has attacks of sickness and becomes drowsy, the surgeon should at once be suspicious of some impending intracranial complication.

If the case be progressing favourably and all the diseased area of bone has been completely removed, granulations do not become exuberant, but form a fine smooth layer over the wound surface, the last portion to become covered being the region of the external semicircular ca.n.a.l and the ridge forming the remains of the posterior wall of the bony meatus.

Exuberant granulation tissue is significant of underlying bone disease.

If patches be observed, a 10% or stronger solution of cocaine should be applied to the part, which should afterwards be curetted. This process may have to be repeated on several occasions until, perhaps, a small spicule of bone is removed, after which granulations usually cease. As a rule the bone is completely covered with granulations by the fifth or sixth week. Meanwhile, owing to the growth of epithelium from the edges of the flaps, the raw surface within the wound cavity gradually becomes smaller, and with this there is diminished secretion.

The gauze packing can usually be discontinued about this period, or considerably earlier, perhaps even by the third week. In its stead an aqueous solution containing 50% of rectified spirit with 10 grains of boric acid to the ounce may be instilled into the wound cavity after it has been cleansed and dried.

Complete cicatrization of the cavity should take place within two or three months, depending on the size of the cavity.

_If the posterior wound has been left open_, the first dressing should be done on the second or third day.

The subsequent treatment depends on each individual case. If the wound has been left open on account of its septic condition, or owing to the dura mater having been exposed and found covered with granulations, its edges may be brought together by sutures after a period of ten days or so, when the wound cavity looks clean, and the packing carried out through the meatus.

On the other hand, if the wound has been left open on account of bone disease involving the inner wall of the tympanic cavity or region of the Eustachian tube, the packing should be continued through the posterior opening until the patches of carious or necrosed bone heal or are exfoliated. In these cases the granulation tissue tends to become fibrous in character in consequence of the necessary curettings, and eventually to form a thickened pad covering the inner wall.

After complete healing has taken place, the patient, before being dismissed, should be warned to visit the surgeon at least once in three months. Owing to the large cavity being lined with epithelium, desquamation takes place to a greater or lesser extent, so that the wound cavity may gradually become filled with ma.s.ses of epithelial debris or cerumen. In consequence the cavity may become septic, and on removal of the epithelial debris underlying ulceration may be found.

This can usually be cured by aseptic treatment, but if granulations have already occurred, curetting and the application of trichloracetic and chromic acid may be necessary.

DIFFICULTIES AND DANGERS OF THE OPERATION

_Anatomical difficulties._ The chief difficulties are due to a middle fossa overlapping the antral cavity, a lateral sinus projecting far forwards and lying superficially, and a sclerosed mastoid having no landmarks to indicate the way into the antrum. Unfortunately these conditions are frequently a.s.sociated.

Formerly it was advised that it was wiser not to proceed further if the antral cavity could not be discovered after chiselling to a depth of three-quarters of an inch. This advice, however, is no longer reliable, as by the combination of the Stacke, Wolf, or Kuster-Bergmann method any anatomical difficulties should certainly be overcome.

An inexperienced operator may mistake a large mastoid cell for the antrum and in this way may get into difficulties. The opening into the antrum, however, can always be identified by pa.s.sing a bent malleable silver probe in an inward and forward direction into the aditus. If only a large cell has been opened, the probe will show that it is a limited cavity.

_Haemorrhage._ In the majority of cases this is more of an inconvenience than a danger, being chiefly due to a general oozing from the soft tissues. It is, however, very necessary that the surgeon should have a clear view of the deeper parts whilst operating. If he works blindly in a pool of blood he courts disaster.

The haemorrhage is best prevented by first curetting away any granulation tissue and then packing the cavity firmly with a strip of gauze. If this be not sufficient, it may be again packed with gauze containing adrenalin solution. It will repay the surgeon to have a good a.s.sistant to keep the field of operation dry. Troublesome bleeding, coming from a small vessel in the bone, may be arrested by the local application of a small fragment of Horsley's sterilized wax (see Vol. I, p. 437).

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