VI. THE COMPLETE MASTOID OPERATION…

VI. THE COMPLETE MASTOID OPERATION

Before considering the question of the radical operation, it is assumed that conservative treatment has been attempted and has failed, and that the middle-ear suppuration has existed for a considerable period.

=Indications.= (i) As a prophylactic measure. If there be merely a perforation of the tympanic membrane and no evidence of disease of the ossicles nor the walls of the tympanic cavity, the probability is that the continuance of the suppuration is due to an affection of the mucous membrane rather than of the underlying bone; for example, to a chronic empyema of a large antrum cavity which, owing to its anatomical structure, will not drain freely.

In such cases the complete mastoid operation is only indicated if the deafness is extreme, the bone conduction diminished, and the high tuning-forks not well heard, or if the ossicles are bound down by adhesions to the inner wall of the tympanic cavity, as it is then obvious that the hearing power cannot be restored completely.

It must, however, be remembered that in many cases a slight discharge may exist for years without giving rise to any complications. If the patient be made aware of the slight danger which exists in every case of middle-ear suppuration, and be in a position to obtain medical attention if retention of pus occurs, then operative measures may be deferred indefinitely. If, on the other hand, the patient intends going to some remote country where medical attendance is impossible, then it is probably wiser to submit to the complete operation rather than risk future trouble.

(ii) If there be recurrent attacks of giddiness, nausea, or headaches radiating up the affected side which are not arrested by the ordinary methods of treatment. These symptoms of retention of pus within the antrum and mastoid process should be considered as danger signals. In this case also it is assumed that the hearing cannot be restored, and in consequence there is no object in performing Schwartze’s operation.

(iii) If there be recurrence of polypi and granulations within the tympanic cavity in spite of curetting, especially if the operation of ossiculectomy has already been performed.

(iv) If there be symptoms of retention of pus due to want of free drainage in the case of stenosis of the external meatus, whether due to fibrous contraction of its soft parts, or from the presence of exostoses.

(v) If cholesteatomatous formation be present. Even if there be no symptoms necessitating immediate interference, operation is usually indicated owing to the fact that cholesteatoma is the commonest predisposing cause of intracranial suppuration and septic thrombosis of the lateral sinus.

(vi) If there be a fistula of the bony wall of the mastoid process, whether it extends anteriorly into the auditory canal or externally through the skin over the region of the mastoid process. It must not be forgotten, however, that simple opening of the antrum and mastoid cells will be quite sufficient if the condition is the result of a recent and acute inflammation of the mastoid process.

(vii) If there be facial paralysis occurring in the course of a chronic middle-ear suppuration. This may mean either that there is bone disease involving the facial canal, or that the inflammatory process has spread through the Fallopian canal towards the inner ear. In either case operation is indicated.

(viii) As a preliminary step in intracranial suppurative lesions of otitic origin.

(ix) In tuberculosis of the middle ear. If the patient’s general condition permits of it, and if the pulmonary disease be slight or arrested, the complete operation should always be done. The difficulty is to remove all the diseased bone. If this can be done the wound will heal quite well.

(x) In acute inflammation of the mastoid process occurring in the course of chronic middle-ear suppuration, the complete mastoid operation should be performed, as in these cases the attic, aditus, and antrum are always involved.

(xi) Amongst the rarer conditions for which the complete operation may be necessary are removal of a foreign body which has been pushed inadvertently into the region of the attic and aditus and cannot otherwise be removed; and actinomycosis of the temporal bone.

METHODS OF OPERATION

The actual method of carrying out this operation varies. For those who have not had great experience the best method is first to open the antrum, as in Schwartze’s operation, and then to remove the ‘bridge’ of bone between it and the tympanic cavity (Küster-Bergmann operation, sometimes called the Schwartze-Stacke operation). Instead of doing this, the upper posterior part of the auditory canal may be chiselled away simultaneously during the act of exposing the antrum (Wolf’s operation). On the other hand, the mastoid and antrum may be exposed from within outwards by removing the outer attic wall and working backwards (Stacke’s operation).

=The Küster-Bergmann (or Schwartze-Stacke) operation.= The preliminary preparation, the position of the patient, and the instruments required are the same as in opening the antrum.

The =incision= is begun just above the upper insertion of the pinna, and is carried downwards in a curved direction behind the auricle along the margin of the skin and scalp. Some authorities prefer to make the incision close behind or even along the post-auricular fold. In favour of the incision being placed far back is the concealment of the scar by the hair. Also, as it is situated on healthy bone somewhat posterior to the actual wound cavity, it should heal by primary union and with no after-displacement of the auricle. In addition, if it be necessary to expose the lateral sinus, this can usually be done by simple retraction of the soft parts.

The exposure of the field of operation is the same as in the simple opening of the antrum, excepting that the soft tissues should be separated a little further forwards and above the external bony meatus, as in this operation the upper posterior wall has to be removed.

The antrum is opened as already described (see p. 382).

The fibrous portion of the external meatus is separated carefully from the posterior wall of the bony meatus by means of a periosteal elevator, and is pulled forward by a retractor. The external portion of the posterior wall is now removed in a wedge-shaped fashion by alternate strokes of the chisel from above downwards (Fig. 221) and from below upwards. The upper level of the bone to be removed corresponds with the zygomatic ridge. After a small portion has been removed, a pair of forceps is passed into the auditory meatus and its point made to project into the wound posteriorly through the end of the now detached fibrous portion of the auditory canal. With the forceps a piece of gauze is drawn through the auditory meatus in the form of a loop. By its means the auricle and fibrous portion are pulled well forward, thus exposing to view the tympanic cavity. Two openings are now seen: one, the auditory canal and tympanic cavity, in front, and the other, the antrum and mastoid cavity, behind. Between them is the ‘bridge’; that is, the innermost portion of the posterior wall of the auditory canal.

Any granulations present are curetted away gently from the tympanic cavity. The seeker is next passed into the tympanic cavity, and its point directed upwards and backwards into the aditus, so that it rests on the floor of the latter, or its point may be inserted into the aditus through the mastoid wound. Beneath it lies the eminence of the external semicircular canal and the facial nerve. This is a most important landmark. Provided the seeker is kept in this position, all the bone lying superficially to it can be removed without injury to the semicircular canal or facial nerve.

In this connexion may be mentioned Stacke’s probe or ‘protector’ (Fig. 222). Although historically an instrument of importance, I do not make use of it. It is so large and of such sharp outline that, unless used with extreme care, it is itself very liable to injure the facial nerve. For this reason I prefer the seeker, a much finer and more delicate instrument, which will serve the purpose without the same risk (Fig. 219).

The ‘bridge’ is now carefully removed by the gouge or chisel, frequent use being made of the seeker meanwhile. As the roof of the antrum, aditus, and attic is a continuous one, the bone to be removed is necessarily at a higher level than the roof of the bony meatus. This is a point which must not be forgotten, as the great fault of the beginner is to remove the bone too low down.

As the aditus is approached, the strokes of the chisel must be very gentle. If too much force be used, the chisel, on breaking through the innermost portion of the ‘bridge’, may injure the deeper-lying parts, more especially the facial nerve.

Some authorities advocate removal of the ‘bridge’ by means of bone forceps. This, however, is not so sure a method as by the chisel or gouge.

After removal of the bridge, the tympanic cavity, antrum, and mastoid will form a continuous cavity. As a rule the outline of the external semicircular canal appears as a well-marked white eminence, and projecting beyond it are the remains of the posterior wall of the auditory canal. In removing this ridge good illumination is essential. The bone is removed in layers with the chisel, beginning at the tip of the mastoid process, and working parallel to the auditory canal and the underlying facial canal. If necessary the seeker may be used as a guide, its point being allowed to rest on the floor of the aditus, superficial to the semicircular canal (Fig. 223).

The amount of bone removed should be such that at the end of the operation the auditory canal is only separated from the main cavity of the mastoid antrum by a slight eminence, the remainder of the posterior wall, which is continuous with that of the external semicircular canal.

Occasionally the facial canal and the stylo-mastoid canal are abnormally superficial. Provided the bone be removed in the manner just described, the facial nerve should not be injured, even though it may be exposed inadvertently. A warning of this occurrence is given by bleeding from the vessels within the canal (see p. 374).

If the malleus and incus be still in situ, they can now be seen and can usually be removed by the curette. No force must be used. Removal of the incus is a matter of no difficulty. In the case of the malleus there may be some resistance owing to the attachment of the tendon of the tensor tympani muscle. If so, the malleus should be grasped by a fine pair of forceps and the tendon severed by means of Schwartze’s tenotomy knife.

The overhanging edge of the outer wall of the attic can now be felt by means of the seeker. It is best removed by gentle taps of the chisel or small gouge. Especial care must be taken not to drive the gouge too far inwards. If this be done inadvertently, the transverse portion of the facial nerve passing along the inner wall of the tympanic cavity may be injured. As a safeguard some surgeons use an attic punch-forceps or a burr, others a Stacke’s protector which should be inserted into the attic before chiselling away its outer wall.

After the outer attic wall has been removed, the roof of the auditory canal and the attic should be continuous. This is verified by inserting the seeker, with its point turned upwards, within the attic, and then withdrawing it; no ridge of bone should now prevent its withdrawal.

Granulations or the epithelial lining of cholesteatomata should be removed from the recesses of the tympanic cavity with a small curette. Care must be taken not to injure the surface of the promontory, or the region of the fenestra ovalis and fenestra rotunda. It is especially important to curette away the mucous membrane from the orifice of the Eustachian tube in order that scar tissue may obliterate its lumen and so prevent reinfection of the middle ear from the naso-pharynx. For this purpose a narrow curette is necessary (Fig. 224).

Removal of the innermost portion of the floor of the auditory canal is not always necessary. Sometimes, however, the ‘hypotympanum’ is well marked, and in order to ensure a good result it is wiser to remove this projecting piece of bone. If the ridge of bone be removed piecemeal, and if the gouge or chisel be kept parallel to the floor of the canal, there should be no danger of wounding the bulb of the jugular vein. Cases, however, have been recorded in which this has occurred.

The final step is to see that no pockets nor overhanging ledges or ridges of bone remain, and that all the diseased area has been removed. The cavity, although irregular in outline, should be a continuous one with a smooth surface (Fig. 225).

=Wolf’s operation.= This slight modification of the Küster-Bergmann operation requires merely a note of description. The position of the patient and the preliminary steps of the operation are the same as in the former operation.

In this operation, instead of first exposing the antrum cavity and afterwards removing the posterior wall of the external meatus, this procedure is performed in one step.

The chisel or gouge is first brought into contact with the bone just behind the upper posterior margin of the auditory canal. The bone is removed in layers by chiselling it away in a forward direction and in such a manner that each stroke of the chisel is carried directly into the auditory canal (Fig. 226). With each successive stroke, begun a little more posterior and inferior to the one preceding it, more bone is removed until at length the antrum is exposed. There should be no risk of injuring the external semicircular canal nor the facial nerve, owing to the fact that the outer wall of the antrum lies superficial to the tympanic cavity and aditus.

After the antrum has been exposed, the technique of the operation is the same as that already described in the Schwartze and Küster-Bergmann operation.

=Advantages.= 1. If the surgeon be experienced it saves much time, as the preliminary steps of the operation can be carried out very rapidly.

2. If the mastoid be sclerosed and there are no landmarks, the antrum, however small, is bound to be reached by making use of this method, by keeping high up, and, if necessary, exposing the dura mater. To verify the depth to which the bone may be removed and also the position of the antrum, the seeker should be inserted occasionally through the tympanic cavity into the aditus.

=Disadvantages.= If the surgeon be not experienced, it is not so safe a method as that of first exposing the antrum.

=Stacke’s operation.= After exposure of the field of operation, as in the Küster-Bergmann operation, the fibrous portion of the auditory canal is separated posteriorly from the bony portion.

Any granulations, together with the malleus and incus, are removed from the tympanic cavity (see p. 353). Under a good illumination, using a head-lamp if necessary, the surgeon passes a seeker along the auditory canal, its point being made to project into the attic in order to define its limits and that of the aditus. The innermost portion of the upper posterior wall of the auditory canal, that is, the outer wall of the attic, is now removed piecemeal by means of a small gouge (Fig. 227). By working backwards the aditus is approached, the bone being removed carefully in small fragments. The seeker is inserted repeatedly into the entrance of the aditus so as to rest on the external semicircular canal, in order that the position of the latter and the underlying facial nerve may be kept constantly in mind. More bone above and external to this point is removed in small fragments, until at length the upper and innermost portion of the antral wall is removed and its cavity thus exposed. The cavity is gradually enlarged by removing still more bone in a backward and outward direction, until finally it resembles that left after the complete operation. Stacke originally devised this method in those cases in which he considered that the disease was limited to the ossicles, the walls of the attic, aditus, and innermost portion of the antrum. It was, indeed, merely a more radical method of performing ossiculectomy.

=Advantages.= Although this operation has practically been abandoned as a method of performing ossiculectomy, yet under the following conditions it may be adopted during the performance of the complete operation:--

1. If the mastoid be very sclerosed and if the antrum cannot be exposed, although the bone has been removed to a depth corresponding to its usual position.

2. If there be difficulty in exposing the antrum in the performance of the radical operation owing to the lateral sinus projecting far forwards and the middle intracranial fossa overlapping it externally.

=Disadvantages.= The chief disadvantage is that it is more difficult and tedious to begin the operation within the depth of the wound, and if the meatus is very deep and narrow it may be almost impossible to carry out.

=Preservation of the ossicles and tympanic membrane after performing the complete mastoid operation.=

This method of operation is well known and has been performed for some years, especially by Jansen of Berlin, and in America.

The only indication for this modification of the complete mastoid operation is disease involving the antrum and mastoid process so extensively as to require complete removal of the posterior wall of the auditory canal, without there being any coexisting bone disease of the walls of the attic or of the ossicles.

As the complete mastoid operation is only performed for some condition due to chronic middle-ear suppuration, it is difficult to imagine that the ossicles and attic region could remain unaffected when the extent of the disease necessitates the complete operation.

In my opinion, if it be necessary to remove the ‘bridge’ it is also necessary to remove the outer wall of the attic and with this the malleus and incus. If, on the other hand, there be no bone disease of the attic region or of the ossicles, Schwartze’s operation, or some modification of it, should be sufficient. The majority of aurists agree that, excepting in those cases in which the continuance of the suppuration is due to an empyema of the antral cavity, the ossicles are almost invariably carious to a greater or lesser extent in chronic middle-ear suppuration. This view is supported by Grunert’s researches (Archiv für Ohrenheilkunde, Band 40), who found that the ossicles were only normal in five cases in a series of 113 cases in which the complete operation had been performed.

Although removal of the ‘bridge’ may eradicate the disease within the mastoid process and antrum, yet, if the ossicles are left, post-suppurative adhesions will almost certainly afterwards bind them down and so cause a greater deafness than if they had been removed originally. Still, a few isolated cases have been reported in which hearing to the extent of 20 feet or more has been obtained as the result of this operation. The same results, however, frequently occur after the performance of the complete operation with removal of the malleus and incus. Until we have a large and consecutive series, recording the results of this particular operation in detail, together with information regarding the duration of the symptoms, the previous treatment, and the condition of the ear before operation, it is impossible to judge the value of this method.

THE FORMATION OF POST-MEATAL SKIN FLAPS

This is done for two reasons: firstly, to prevent stenosis of the auditory canal; and secondly, to aid the growth of the epithelium over the wound surface, so that the latter will heal as rapidly as possible.

These flaps may be formed in several different ways. The following is the technique I adopt: A long, narrow, curved bistoury is passed down the auditory meatus so that it projects through the detached end of the fibrous portion, its point being directed backwards. The auricle is held well forward and the fibrous portion of the meatus cut through posteriorly, from within outwards, for a short distance (Fig. 228). The edge of the bistoury is then directed in a slanting direction upwards and outwards, and the incision continued as far as the cartilaginous portion of the meatus, care being taken not to cut into the concha. The bistoury is then withdrawn and reinserted at the point at which it was first made to turn upwards. It is now directed downwards and outwards and, in a similar manner, the incision is made in a slanting direction towards the inferior margin of the cartilaginous meatus. In carrying out these manipulations care must be taken that the outer portion of the bistoury does not injure the tragus or other portion of the auricle, a mistake which can easily occur. The fibrous portion of the meatus is thus divided by a Y-shaped incision into three small flaps; namely, a posterior or external V-shaped flap, and a superior and an inferior flap (Fig. 229).

The outer flap is fixed to the skin behind the auricle by means of a catgut suture (Fig. 230), and the auricle is then pulled back into its normal position. By inserting the tip of a finger into the meatus, the upper and lower flaps are pressed upwards and downwards against the roof and floor of the mastoid cavity, and can be kept in position afterwards by suturing the flaps to the subcutaneous tissue or by packing the cavity through the meatus with a strip of ribbon gauze.

Amongst other methods the following may be mentioned:--

=Körner’s method= (Fig. 231). Two parallel incisions are made in a longitudinal direction through the fibrous portion of the posterior wall of the meatus and are prolonged outwards as far as the concha. On the auricle being restored to its normal position, this posterior flap is pressed backwards and so covers a large area of the posterior wound surface. The chief objection to it is that, owing to involvement of the concha, there is considerable enlargement of the meatal opening and therefore subsequent disfigurement.

=Panse’s method= (Fig. 232). A transverse incision is carried through the posterior margin of the meatus, at the junction of the concha and auditory canal posteriorly. With a pair of scissors or knife, the posterior wall of the fibrous portion of the canal is now split by a longitudinal incision. In this way two flaps are formed, a superior and inferior one. They are fixed into position by catgut sutures through the subcutaneous tissues at the upper and lower angles of the wound.

=Stacke’s method= (Fig. 233). This consists of a large inferior flap, formed by making a longitudinal incision along the posterior upper border of the fibrous portion of the auditory canal and a transverse incision meeting it at right angles, the latter cutting through the fibrous portion of the meatus at its junction with the concha.

In order that these flaps may be thinner and more adaptable, the subcutaneous tissue should be cut away. Of these flaps the Y-shaped one is the most practicable, as it is suitable whether the posterior wound is closed or left open.

Körner’s method has the objection that there is subsequent disfigurement owing to the large meatal opening formed by cutting into the concha. It has the advantage, however, that the large posterior flap will cover the posterior surface of the wound cavity to a considerable extent, and also that it will permit a good view of the surface.

Panse’s flap is only of service if the posterior wound is left open and if there is not sufficient tissue left to make a posterior flap owing to previous destruction of the posterior wall of the auditory canal.

Stacke’s method is good if skin-grafting is afterwards employed.

CLOSURE OF THE WOUND

Excepting under the conditions mentioned below, the posterior wound is closed by bringing together the edges of the skin incision with fine silkworm-gut sutures (Fig. 230). Before this is done, the wound cavity should be irrigated with a weak solution of biniodide of mercury, dried, and the deeper parts of the wound plugged with a strip of gauze inserted through the external meatus. This will not only arrest the hæmorrhage and keep the inner part of the wound dry, but at the same time will keep the skin flaps in position. After the wound has been closed, firm pressure should be applied in front and behind the ear to press out any blood from the cavity.

As a final step the gauze which has been inserted into the meatus is removed, and the cavity again packed evenly and lightly from the bottom of the wound with a fresh strip. The ear and surrounding parts are protected with a pad of sterilized gauze covered with cotton-wool and kept in position with a bandage.

The posterior wound should be left open under the following circumstances:--

1. If there be an abscess over the mastoid process. Although it may be possible to excise the whole of the lining membrane of the abscess cavity, it is wiser to leave the wound open for the first few days. The innermost portion of the wound cavity is packed through the external meatus, only the superficial part being packed through the posterior wound incision. As healthy granulations appear, the posterior packing is diminished, so that the edges of the incision gradually come together. If necessary, the edges of the wound can also be freshened and brought together by silkworm-gut sutures under cocaine anæsthesia.

2. If there be extensive disease of the bone, especially if the dura mater and lateral sinus are covered with septic granulations.

3. If there be bone disease of the anterior and inferior parts of the tympanic cavity. The after-treatment of packing or the curetting away of granulations can be carried out more easily through the posterior wound than through the external meatus, as it gives a better view of these regions.

4. In young children it is frequently advisable to leave the posterior wound open owing to the difficulty of packing the wound cavity through the small external meatus.

SKIN-GRAFTING AFTER THE MASTOID OPERATION

In order to shorten the duration of healing, a large Thiersch’s skin graft may be transplanted into the wound cavity. If this procedure be adopted it may be carried out in several ways. The skin may be transplanted in one large piece or in several small portions, and it may be introduced into the wound cavity either immediately after the completion of the mastoid operation or from seven to ten days later.

There is considerable diversity of opinion as to whether skin-grafting should be employed or not, and also when it should be done.

This may be partially accounted for by the fact that although, theoretically, the application of skin grafts is easy, yet, practically, the technique is difficult. Those who favour skin-grafting point to the fact that healing of the wound may take place within five weeks, whereas, if grafting be not undertaken, cicatrization of the cavity, even under favourable conditions, can hardly be expected to occur before eight to twelve weeks.

The skin-grafting operation as suggested by Charles Ballance is generally performed as a second stage, some ten or more days after the primary operation. This, from the patient’s point of view, is a serious matter; and the disappointment caused by the grafting not being always successful has induced many to give it up and to be content with what seems to be a more certain, though more prolonged, after-treatment.

More recently, however, it has been shown that in suitable cases skin grafts, if applied at the time of the completion of the primary operation, will take just as well as at a later date. This altogether alters the aspect of the case. If at the end of the primary operation it be certain that all the diseased bone has been removed and the cavity has been rendered aseptic, there can be no objection to the immediate application of skin grafts. If the result be successful, the period of after-treatment is considerably curtailed. If, on the other hand, it be not successful, the patient, beyond having a raw surface on his arm or leg for a few days, is no worse off than if the graft had not been applied.

Skin-grafting, however, cannot be done in every case. Two conditions are necessary for its success: firstly, that all the diseased bone has been removed; and secondly, that the wound cavity is aseptic.

Immediate skin-grafting, therefore, should not be employed if, in addition to the chronic disease, there be acute inflammation of the mastoid process, or of the subcutaneous tissues covering it; nor should it be done if it has been necessary to expose the dura mater over a large area, nor if there be any possibility of some subsequent intracranial complication. In such cases it may be justifiable to do skin-grafting after the acute symptoms have subsided. If, however, the case be progressing satisfactorily, the advisability of submitting the patient to a second operation should be a matter of careful consideration.

Disease of the inner wall of the tympanic cavity, or around the orifice of the Eustachian tube, is also a contra-indication against grafting, as the graft, if applied, will not take over these areas. The author’s opinion with regard to skin-grafting is that, if it can be applied immediately after the completion of the primary operation (and the conditions justifying this are limited), it may be done. If, however, the conditions be such that they will not permit of this, it should not be done at all.

=Technique.= When the grafting is done at the completion of the mastoid operation. The first step is to see that the mastoid wound cavity is rendered thoroughly aseptic and dry. All bleeding points in the soft tissues are arrested by means of pressure forceps. The mastoid cavity is then filled with hydrogen peroxide lotion, which is afterwards syringed out with a warm saline solution, the cavity being dried with sterilized strips of gauze, and finally packed from the bottom with a fresh strip.

The size of the graft, which is usually taken from the thigh, should be at least 2 inches in width and 4 inches in length. The skin is cleansed by washing it with soap and water, then with ether, and finally with normal saline solution, the part being afterwards dried with a sterilized towel. It does not matter what type of razor is used to remove the graft, so long as it is sharp. The chief point to observe, in order to secure success, is to see that the skin is kept uniformly stretched--the tighter the better. The technique of removal of grafts is described elsewhere (see Vol. I, p. 670). The graft taken from the leg is transferred to a large spatula and smoothed out over its surface. The auricle is now pulled forward, and the gauze strip is removed from the mastoid cavity. The spatula is laid across the surface of the cavity so that it rests on the anterior margin of the wound surface (Fig. 234). With a sharp probe the edge of the graft, which just overlaps the spatula, is held in position at this point, the spatula being gently retracted so as to leave the graft stretched across the surface of the wound cavity. With a ‘stopper’ (Fig. 235), the graft is now pushed inwards towards the tympanic cavity.

A glass pipette (Fig. 236), having a curved beak, is then passed inwards beneath the graft until its point, directed downwards, lies within the tympanic cavity (Fig. 237). Any blood which has accumulated between the bone and the graft is now sucked out, and in doing this the graft becomes closely applied to the bone surface (Fig. 238). After removing the pipette, any part of the graft which is not adherent to the bone is smoothed out over its surface. The tympanic cavity and the innermost portion of the mastoid cavity are then plugged with sterilized pellets of cotton-wool wrapped in gauze and dusted with aristol powder. The outer portion of the cavity is filled up with a strip of gauze, its end being brought out through the external auditory meatus.

The posterior part of the graft, still projecting beyond the posterior margin of the wound, is now turned forwards so as to form a covering over the gauze filling up the wound cavity (Fig. 239). On the auricle being restored to its normal position, this portion of the graft is brought into contact with the subcutaneous tissues of the skin forming the post-aural flap, which now forms the outer wall of the mastoid cavity. The posterior incision is closed with sutures and a dry dressing and bandage are applied to the ear.

If skin-grafting be performed a week or more after the primary operation. The post-aural wound, now healed, has to be reopened. In doing so there may be considerable bleeding, which must be arrested. The mastoid cavity is usually found to be covered with a fine layer of granulations. They are curetted away carefully, special attention being paid to the region of the Eustachian tube and the floor of the tympanic cavity. After removal of the granulations, the bone should appear uniformly smooth though somewhat vascular. If any points of carious bone be found they should be removed freely with the gouge or burr. Considerable time may have to be spent in arresting the oozing from the surface of the bone cavity. This is best done by washing out the cavity with hydrogen peroxide solution and then plugging it tightly for a few moments with adrenalin solution. The gauze is withdrawn in a few moments. If there be still oozing, the pressure will have to be repeated until it ceases. The method of applying the graft is the same as already described.

=After-treatment.= The outer dressing may be changed every second day, but the wound itself is not interfered with until the eighth day. If asepsis has been obtained, the posterior wound has usually completely healed, so that the stitches can be removed at the first dressing. Owing to the secretion from within the cavity there may be a certain amount of odour, and as a rule some purulent discharge from the meatus. Under good illumination the strip of gauze is gently removed through the meatus and afterwards the small pellets of cotton-wool. In order to make certain that all are removed, a note should be made at the time of transplanting the graft as to how many were inserted in the wound cavity. The ear is now syringed out gently with a weak solution of hydrogen peroxide and afterwards dried by mopping it out with small wicks of cotton-wool.

A speculum is next inserted into the meatus and the cavity thoroughly examined. Any portions of the graft not in absolute contact with the bone or which overlap the skin of the meatus will have died, and can be removed by forceps. Care, however, must be taken not to pull off these portions too forcibly, as in doing so other pieces of the graft may be torn away. The external meatus is then plugged with a tiny piece of gauze and a dry dressing applied. If the graft has not taken and has died, it will be expelled at the first dressing on syringing.

Further treatment consists in syringing and afterwards drying the cavity daily. From day to day the outer layer of the graft will gradually come away piecemeal. At the end of the second week the patient can usually go home and carry out the treatment for himself, but he should be seen by the surgeon at least once a week until complete healing has taken place. If the graft has not taken uniformly over the surface of the bone, small patches of granulations may be seen covering these areas. Under cocaine anæsthesia these patches should be curetted. If the granulations recur repeatedly, it means that there is some underlying carious bone, and that healing will not take place until the tiny fragment is eventually exfoliated.

=Results.= Statistics vary. There is no doubt that the results are better according to the experience of the surgeon with regard to grafting. If it be only applied in those cases in which it is certain that all the diseased bone has been eradicated at the primary operation, then the percentage of success with relation to failure is very high. If, however, skin-grafting be adopted as a matter of routine, the ultimate result is probably not so good as in a similar series of cases in which grafting has not been done.

=Skin-grafting through the external meatus.= This has been advised chiefly in order to avoid a second operation.

The technique of applying the graft is practically the same as that for transplanting a large graft. The same care must be taken to get the interior of the mastoid cavity aseptic and dry. To avoid a general anæsthetic, the small grafts may be removed from the arm or leg under local anæsthesia produced by a subcutaneous injection of Schleich’s solution. The graft is transferred from a small spatula to the edge of the meatus and then coaxed into position within the cavity by means of probes. The grafts are kept in position by small pellets of cotton-wool covered with gauze. If successful, the grafting may shorten the duration of the after-treatment. It is not, however, so satisfactory a procedure as applying a large graft directly through the post-aural wound.

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 glass tube, having attached to the other end a piece of rubber tubing with a glass mouthpiece or small rubber bag. The graft at the end of the tube is passed 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 stitches 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 canal 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 canal 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 masses of epithelial débris or cerumen. In consequence the cavity may become septic, and on removal of the epithelial débris 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 associated.

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 Küster-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 passing 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.

Hæmorrhage. 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 hæmorrhage 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 assistant 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).

Wound of the lateral sinus. This is a serious matter for two reasons: firstly, it may prevent completion of the operation; and secondly, it may lead to infection of the sinus.

If the sinus has already been exposed before the accident occurs, the surgeon promptly arrests the hæmorrhage by placing the forefinger of his left hand directly over the wound in its wall and exerts sufficient pressure to completely obliterate the sinus at this point. With his finger kept in this position, the wound cavity is carefully dried, and, if there be sufficient room, a piece of sterilized gauze is then packed between the bone and the outer wall of the sinus, both above and below the site of the injury. If there be not enough room to do this, then the surgeon with his right hand, or the assistant, should punch away more bone by means of bone forceps. After the lumen of the sinus has been obliterated above and below the injured area, the finger may be removed. If the packing has been successful, there will be no bleeding; if there be still slight bleeding, it can be controlled by further pressure. If possible, this method should always be carried out, as it practically excludes any chance of after-infection of the sinus.

If the injury takes place before the sinus has been sufficiently exposed to permit of direct pressure with the finger, then the only thing to do is to press in a small strip of gauze and plug the opening. As to what should be done next is a matter of opinion. Some surgeons are content to leave the gauze in situ. The author prefers to expose the sinus further, as in the former case, and to make certain that it is obliterated above and below the injured area. No doubt, if the injury be slight, the pressure of the strip of gauze covering the puncture will be sufficient to control the hæmorrhage, and the patency of the sinus may be maintained on healing. At the same time infection of the sinus has been known to take place, although the symptoms of this may not occur for ten days or two weeks after the operation.

If the sinus projects far forwards the gauze plugs may so inconvenience the operator as to prevent him completing the operation, which therefore may have to be delayed for at least a week. If, however, the sinus be injured at an early stage of the operation and the symptoms for which it is being performed are urgent, then, in spite of all difficulties, the antrum, at any rate, must be opened to permit of drainage, the operation being completed at a later date.

Injury to the facial nerve. The nerve may be injured in any part of its course within the tympanic cavity, or in its vertical course through the stylo-mastoid canal. To avoid this injury, curetting of the tympanic cavity should always be performed gently, and care should be taken not to chisel too low down,--the usual fault of the inexperienced.

Twitching of the face means that the nerve has been touched. If the patient be under deep anæsthesia, it is difficult to say whether the nerve has been injured or divided. In a case of doubt, it is wiser to discontinue the anæsthetic until the conjunctival reflex returns, when it can easily be demonstrated whether the facial nerve is affected or not.

If the injury be the result of curetting, it is wiser to do nothing. Recovery almost invariably takes place, owing to the fact that the paralysis has been caused by slight injury of the nerve. If, however, the nerve has been chiselled through, and the injury has occurred in its lower portion, it should be freely exposed over this area. The severed ends of the nerve should then be approximated and left in situ. In this case permanent paralysis is possible.

The after-treatment consists in avoidance of pressure in packing, the giving of strychnine internally, and faradism or galvanism to keep up the tone of the facial nerve and the muscles it supplies. Careful testing of the electrical reaction will show whether nerve regeneration is taking place or not. If the paralysis has existed for six months, and if in addition there be a definite reaction of degeneration, then the question of anastomosing the peripheral portion of the facial nerve to the spinal accessory, or what is more advisable, to the hypoglossal nerve, may be considered (see Vol. I, p. 452).

Injury to the labyrinth. Of the semicircular canals the external is the more liable to injury. The cochlea may also be injured from violent curetting of the promontory, or infected from dislodgment of the stapes; or it may even happen that a careless operator may inadvertently chisel through the promontory itself. In consequence of these accidents, vertigo, vomiting, and nystagmus may persist for several days, but as a rule they gradually diminish and disappear.

The treatment is expectant. As a result of pyogenic infection, suppuration of the labyrinth may occur. Even if this does not take place, complete deafness may result.

Injury to the dura mater. The subsequent danger is meningitis, fortunately a rare occurrence. The immediate treatment is to irrigate the part with weak biniodide of mercury solution, and then to remove more bone over the site of the injury. The intracranial pressure will keep the dura mater in close contact with the bone, so that if subsequent infection occurs there will be free drainage. The site of injury should be carefully isolated from the general mastoid wound cavity by covering it with sterilized gauze. If signs of meningeal irritation occur, the wound should be inspected, and if there be any evidence of localized meningitis, it should at once be surgically treated.

RESULTS OF THE OPERATION

=With regard to life.= If, at the time of the operation, the disease be limited to the mastoid cavity, there should be no immediate danger to life.

=With regard to recovery.= (i) The operation is successful. Roughly speaking this occurs in at least 80% of the cases, complete healing taking place within eight to twelve weeks. If skin-grafting has been successfully performed the duration of healing may be considerably shorter. If the bone disease has been eradicated with complete healing of the cavity, the possibility of intracranial complications in the future can be excluded. On this account the patient may be considered as a healthy individual from an insurance point of view.

(ii) The after-treatment may be prolonged. The chief causes of delay in healing and continuance of the suppuration are sepsis and caries of some part of the bony wall, usually the promontory or floor of the tympanic cavity, or around the orifice of the Eustachian tube. In the former case the use of ear-baths of hydrogen peroxide or of rectified spirit, or frequent syringing of the cavity with a weak biniodide of mercury solution, and afterwards drying it and protecting it with gauze, may be sufficient to effect a cure. In the latter case the local condition must be treated.

Another condition delaying cure is reinfection from the throat through a patent Eustachian tube. In this case, although the mastoid cavity becomes lined with epithelium, mucous membrane may still cover not only the region around the Eustachian orifice, but the main portion of the tympanic cavity. The chief object in these cases is to close the orifice of the Eustachian tube. Sometimes this can be done by curetting under cocaine; in other cases by actual cauterization. After closure has been obtained, the cavity should be dried and gently packed with gauze impregnated with boric acid or aristol powder.

Again, cholesteatomatous formation may be the immediate cause of relapses. In these cases it is very difficult to remove all the diseased tissue. Even although the patient may apparently be cured, yet, unless kept under close observation, recurrence of cholesteatomatous masses take place, and frequently cause further caries of the underlying bone.

Finally, delay in healing may be due to careless after-treatment: if the cavity has not been properly packed, granulations spring up in the region of the aditus and gradually form a partition between the mastoid and tympanic cavities. If this takes place, further disease of the bone may occur owing to the retention of the secretion.

(iii) Symptoms may occur pointing to some intracranial complication, and further operation may become necessary.

=With regard to hearing.= The hearing power depends not only on the condition before operation, but also on the result of the after-treatment. The average hearing power after the removal of the malleus and incus is about 12 feet off for ordinary conversation. The same result should be obtained after the complete mastoid operation, provided there be no internal-ear deafness and provided the stapes be not already ankylosed within the fenestra ovalis. If the patient before operation hears conversation at a greater distance than 12 feet he should be told that the hearing power may be reduced to this amount. If, however, there be considerable deafness, due to polypi or granulations blocking up the tympanic cavity and auditory canal, the hearing power may be improved by the operation. The ultimate hearing depends on the condition of the stapes within the fenestra ovalis: if it remains freely movable, the hearing power may be extremely good. The great object, therefore, of the after-treatment is to prevent the inner wall of the tympanic cavity becoming covered with granulations which may become organized later into a fibrous pad covering the inner wall of the tympanic cavity, and thus prevent movement of the stapes and, in consequence, marked deafness. The prevalent idea that the hearing power is destroyed irrevocably, as a result of the complete operation, is quite wrong: equally so is the harmful statement that, as a result of this operation, complete restoration of the hearing can be obtained.

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VII. OPERATIONS UPON THE LABYRINTH

GENERAL CONSIDERATIONS

Labyrinthine suppuration usually occurs in the course of a chronic middle-ear suppuration; more rarely, as the result of tuberculous disease of the temporal bone, or in consequence of an acute middle-ear suppuration. In the latter case, however, it is a matter of experience that, although symptoms of labyrinthine suppuration may be present, they almost invariably subside as a result of drainage of the middle ear and mastoid. This is an important point which should be remembered, as otherwise the labyrinth may be explored unnecessarily at a considerable risk to the patient’s life.

The most frequent paths of extension of the pyogenic infection from the middle ear to the internal ear are through the external semicircular canal, the promontory, and the fenestra ovalis, the result of cholesteatomatous erosion, caries, or necrosis. Hinsburg, in 198 cases of labyrinthine suppuration, traced the infection in 61 cases. In 27 cases the infection had entered through the external semicircular canal, in 17 through the fenestra ovalis, in 7 through a fistula of the promontory, in 5 through the fenestra rotunda and ovalis, and in 5 through a fistula in the posterior or superior semicircular canal (Archives of Otology, 1902, vol. xxxi, p. 116).

Although operations on the labyrinth are practically limited to suppurative disease, yet under certain conditions they are justifiable when no suppuration is present.

These operations may consist in partial or complete opening of the semicircular canals, or of the vestibule, or in removal of the cochlea, or complete extirpation of the labyrinth.

INDICATIONS FOR OPERATION

(i) =In non-suppurative labyrinthitis.=

(a) To relieve vertigo. This operation is only justifiable if the condition cannot be cured by other methods, and is so distressing as to render the patient’s life unendurable.

In such cases it is first essential to make certain that the attacks of vertigo originate from some lesion within the semicircular canals. For this reason the other forms of vertigo must be excluded, and, in addition, there should be evidence of definite involvement of the labyrinth, such as falling over of the patient to the affected side, internal-ear deafness, or post-suppurative changes within the middle ear, suggestive that the internal ear has also become affected. It must, however, be remembered that it is possible, though extremely rare, for a lesion, limited to the semicircular canals, to produce marked vertigo without any deafness being present, in which case the operation will be limited to extirpation of the semicircular canals.

(b) To relieve tinnitus. If the tinnitus be unbearable and all other measures have failed to cure it, the question of extirpation of the cochlea, in order to destroy the nerve-terminals, may be discussed. This operation, so far, has not been completely successful, and therefore it cannot be recommended.

In this connexion it may be mentioned that, instead of attacking the cochlea, it has been proposed to divide the auditory nerve before it enters the internal meatus. Charles Ballance has recently described such a case.

The difficulty of this latter operation and the very slight chance of cure which it offers, owing to the tinnitus probably being central, are sufficient to raise the question as to whether such an operation is really justifiable.

(ii) =In suppurative labyrinthitis.= The object of the operation is to remove the infective focus and, by permitting drainage, to prevent further complications, such as meningitis or intracranial suppuration.

Before deciding the question of operation every means available should be used to determine: (1) whether the symptoms are merely the result of disturbance of the labyrinthine function in consequence of suppuration still limited to the tympanic and mastoid cavities; (2) whether the labyrinthine lesion is localized or general; (3) whether the labyrinthine suppuration is associated with some intracranial complication, more especially meningitis or cerebellar abscess.

Suggestive of labyrinthine suppuration are vertigo, vomiting, spontaneous nystagmus, and disturbances of the equilibrium. In the more acute cases there may be loud tinnitus, pyrexia, rapid onset of deafness (with inability to hear high tuning-forks and loss of bone conduction), facial paralysis, and deep-seated pain.

In addition much information may be gained by determining the character of the spontaneous nystagmus, if present, or whether nystagmus can be elicited by Bárány’s caloric tests.

(a) If the ear be normal, there is no spontaneous nystagmus.

If, however, the ear be syringed with water above or below the body temperature, a rotatory nystagmus will be obtained if the patient’s head is kept in the erect position, or a horizontal nystagmus if the patient is lying in the horizontal position with the face upwards.

Syringing with hot water causes a nystagmus directed towards the ear syringed; syringing with cold water, away from the ear.

(b) If there be a localized labyrinthine lesion, and the function of the labyrinth is still maintained, the same results will be obtained on syringing. Care, however, must be taken that the syringing is not forcible, otherwise the caloric tests will be unreliable, as in these cases nystagmus may be produced on even slight increase of pressure within the external auditory canal, and with this there may be a sensation of giddiness and nausea.

Spontaneous nystagmus, however, will probably be present, and will be directed towards the affected side. This spontaneous nystagmus is greatly modified by the caloric tests, being strongly exaggerated on syringing with hot water, and weakened or arrested on syringing with cold water.

(c) If the function of the labyrinth be destroyed, as in suppurative labyrinthitis, nystagmus will not be produced as a result of the caloric tests, but the spontaneous nystagmus, if present, will be directed towards the opposite, the normal side.

These various tests must be taken in combination with the symptoms, and frequently are of extreme value in deciding whether operation is indicated or not.

The chief difficulty is to exclude the possible existence of a cerebellar abscess (see p. 460). In favour of labyrinthine inflammation is complete internal-ear deafness, although this in itself does not exclude an accompanying intracranial lesion.

1. Immediate exploration of the labyrinth is indicated (provided there is internal-ear deafness):--

(a) If symptoms of acute labyrinthine suppuration occur in the course of a middle-ear suppuration, even although at the time of opening of the mastoid no definite fistula of the labyrinthine wall can be discovered.

(b) If symptoms of involvement of the labyrinth be present and a definite fistula is found on operation.

(c) If symptoms of a cerebellar abscess or of meningeal irritation be present in addition to those suggestive of a labyrinthine affection.

2. Opening of the labyrinth should be delayed if Bárány’s and other tests show that the labyrinth is not yet destroyed:--

(a) If, in spite of clinical symptoms pointing to involvement of the labyrinth, pus be found under tension within the tympanic cavity or the mastoid process.

(b) If the symptoms before operation consist only of attacks of vertigo and nystagmus, and on operation merely an erosion of the outer wall of the labyrinth (usually the external semicircular canal) is discovered.

In the above cases, if the symptoms be due to irritation of the labyrinth, a rapid recovery is to be expected as a result of the mastoid operation. If, however, they continue or become progressively worse, then the wound cavity must be reopened and the labyrinthine wall carefully examined and further operation undertaken.

The reader may again be reminded that although exploration of the labyrinth is indicated when it is certain that a suppurative lesion exists, yet it is a very serious mistake to open up a labyrinth not yet infected.

Although a great advance has been made in the last few years with regard to operations on the labyrinth, yet there is still much to be learnt, not only with regard to the indications for operation but the result obtained by operation. Now that operations on the labyrinth have become universal, the general tendency is to operate on the immediate occurrence of symptoms of labyrinthine irritation without waiting to see whether simple opening of the mastoid process will not be sufficient--a matter much to be regretted.

=Surgical Anatomy.= The facial canal, it will be remembered, extends horizontally backwards above the promontory, and passes downwards superficially to the inferior portion of the vestibule which lies between the fenestra ovalis below and ampullary ends of the external and superior semicircular canals above. The nerve then extends directly downwards towards the stylo-mastoid foramen, being situated deeply within the posterior meatal wall.

Of the semicircular canals the external is the most prominent, and the only one visible during the performance of the ordinary mastoid operation; its outer border forms the inner and lower boundary of the aditus, and can usually be recognized as a white eminence. The superior semicircular canal can only be seen on careful removal of the overlying bone; its ampullary end is found lying just above that of the external canal. It forms the highest point of the labyrinth, becoming fused with the innermost portion of the tegmen tympani, and is in such close relationship with the upper surface of the petrous bone as to cause a smooth elevation on its surface. It is at this point in the operation of removal of the semicircular canal that the greatest risk is encountered of breaking through the petrous bone and of injuring the dura mater.

The posterior semicircular canal lies at right angles to the external canal, and is best exposed by careful removal of bone just posterior to the latter (see Fig. 240).

The outer half of the first whorl of the cochlea is formed by the promontory. Anteriorly it is in close relationship with the carotid canal, whilst below it lies the dome of the jugular fossa. Medially the modiolus is only separated from the internal auditory meatus by a very fine rim of brittle bone, which can easily be broken; a mishap which may permit of escape of the cerebro-spinal fluid, and also of possible infection of the meninges through the internal meatus.

METHODS OF OPERATING

These operations may be divided into: (1) simple curetting away of a localized lesion of the labyrinthine wall; (2) opening up of the vestibule with removal of the semicircular canals; (3) opening of the cochlea; (4) a combination of these methods--extirpation of the labyrinth.

=Curetting away of a localized lesion of the labyrinthine wall.= It has been already stated that, provided the labyrinth be not yet destroyed, it is not justifiable to explore it on the mere discovery of an erosion of the semicircular canal. At the same time, if a definite fistula from which granulations protrude is present, a small fragment of bone may be chipped away, the granulations being afterwards removed by the curette. Unless pus is found to exude from the labyrinth, it is not necessary to do anything further at the present moment. If, however, at a later period, symptoms of labyrinthine infection occur, then it is necessary to further explore the semicircular canal and vestibule, the extent of the operation depending on what is discovered at the time of the operation.

Sometimes an examination of the tympanic cavity may be prevented before operation owing to the auditory canal being filled with polypi or granulations. On performing the complete mastoid operation and curetting away these granulations and polypi, a fistula may be found in the promontory, and carious bone may be felt on probing. Not infrequently these cases are tuberculous in origin and are accompanied by facial paralysis. Provided there be no labyrinthine symptoms, it is sufficient to curette out the granulations, but only gently. Violent curetting may break through the barrier between the infected area and the internal meatus and so lead to meningitis. It is wiser to curette too little than too much.

A further condition which may be met with is necrosis of a portion of the promontory, or of the walls of the vestibule, or of the semicircular canals. If the sequestrum be not quite loose at the time of operation, it should be left in situ, provided there be no intracranial symptoms. In fact, there is less danger in leaving the sequestrum than in attempting to remove it. After the operation, the wound cavity is kept open, so that the sequestrum can be removed at a later date after it has separated from the living bone.

=Opening the vestibule= (with partial or complete removal of the semicircular canals). This may be performed by one of the following methods:--

Above and behind the facial nerve through the semicircular canals. The complete mastoid operation is performed first. The chief difficulty is to expose the field of operation so as to obtain sufficient room for the necessary manipulations. To do this the following steps should be carried out: The tip of the mastoid process and the remains of the posterior wall of the auditory canal are removed to their extreme limit without injury to the underlying facial nerve. The floor of the auditory canal is also chiselled away until the lower level of the tympanic cavity is brought freely into view, the amount of bone removed depending on the anatomical condition found. To expose the anterior portion of the tympanic cavity, the skin incision is extended slightly forwards, but not far enough to wound the temporal artery, the soft tissues being then separated from the bone and the auricle pulled still further forwards and downwards.

Skin meatal flaps are now fashioned--either the Y-shaped flap or Stacke’s flap (see p. 403)--and are afterwards kept in position by means of sutures. Good illumination is necessary, and for this reason a head-light should be used. One assistant is employed to retract the soft tissues from the wound, another to keep it as dry as possible.

The exposed portion of the external semicircular canal is first identified. If the bone be soft, the arches of the semicircular canal should be defined (Fig. 240). The posterior canal will be discovered by gouging away the bone just posterior to the arch of the external semicircular canal, and the superior, by working inwards and upwards towards the roof of the attic. If the outline of the canals can be made out, the further steps of the operation are rendered very much easier. Unfortunately, the bone is sclerosed in the majority of cases, rendering anatomical exposure of the canals an impossibility.

The next step is to remove the eminence of the horizontal semicircular canal. This is best done by means of a small gouge and mallet. Some prefer a burr, specially constructed to cut vertically; others a chisel. I prefer a fine gouge. As the facial canal runs along the lower anterior portion of the external semicircular canal, the gouge should be directed in a backward direction in removal of the outer wall of the latter, so as to cut away from the facial canal.

The surgeon should be content to remove the bone piecemeal, as, owing to its brittleness, it is very apt to splinter, or the point of the gouge itself may slip and so injure the facial nerve.

After an opening has been made into the canal, it should be enlarged by following the canal forward until its ampulla is reached. After this has been done, a fine probe, bent at a right angle (Schwartze’s seeker will do very well), is passed into the opening, and the limits of the vestibule made out as far as possible. The bone is then removed in an upward direction until the ampulla of the superior canal is reached. The opening may then be extended backwards so as to remove the outer wall of the vestibule, that is, the portion of bone which lies between the ampullæ of the superior and external canals.

If the bone be sclerosed, so that it is impossible to find the superior and posterior canals, then, after opening the exposed portion of the external semicircular canal, the bone should be chiselled away at the area marked out in Fig. 240. By this means the vestibule will certainly be reached, and from this point its opening can be extended in any given direction. A sufficient opening should be made so that the inner portion of the vestibule can be seen (Fig. 241). During each step of the operation a clear view must be obtained.

Not infrequently the facial nerve is exposed or pressed upon in chipping away the outer wall of the external semicircular canal, as will be shown by sudden twitchings of the face. If the surgeon be careful, and works in a direction away from the nerve, it should not be injured. If possible, the outer margin of the horizontal semicircular canal, together with the Fallopian canal, should be left intact as a bridge crossing the vestibule. If necessary, the external and superior canals can be removed in their entirety. A fine probe is inserted into the lumen of the canal so as to tell its direction, and its outer wall is then burred away. For this particular purpose a burr should be used as soon as the surgeon has got beyond the region of the facial nerve. After a view of the interior of the vestibule has been obtained, the ampullary nerves may be destroyed by means of the curette or with pure carbolic acid at the end of a probe. Removal of the posterior canal is best effected by opening it just behind the external semicircular canal and following it out in an upward direction until it meets the superior, and then downwards until it enters the vestibule. This extensive operation is one of extreme difficulty and seldom necessary.

Posterior to the semicircular canals: Neumann’s method. Neumann enters the vestibule posteriorly. The bone forming the inner wall of the antrum is removed by means of bone forceps or gouge and mallet until the posterior semicircular canal is opened. By this means the posterior surface of the petrous bone can be exposed as far inwards as the internal auditory meatus.

Below and anterior to the facial nerve through the promontory. The preliminary steps of the operation having been performed and the field of operation freely exposed, the stapes, if still present, is extracted by means of a small hook passed between its crura. The bridge of bone between the fenestra ovalis and fenestra rotunda is then cut through by light taps on a very fine gouge. The bone is removed by attacking the lower limit of the fenestra ovalis, and working downwards until the fenestra rotunda is reached. With a fine curette or scoop the loosened fragments of bone are removed. Care must be taken not to work above the region of the fenestra ovalis or the facial nerve will probably be injured. After a sufficient opening has been made, a bent probe can be passed through the opening in the promontory in an upward and backward direction behind the facial nerve into the inferior and anterior portion of the vestibule (Fig. 241).

=Removal of the cochlea.= If necessary, the first turn of the cochlea can now be removed by gouging away the promontory from behind forwards. If the anterior wall of the external auditory canal interferes with this being done, it may be partially removed by means of the gouge and mallet. After the first half-turn of the cochlea has been opened, its contents may be curetted out, care, however, being taken to avoid the carotid canal, which lies in close relationship with its anterior inferior portion. If the bone be carious only gentle curetting is necessary. If, however, this be not the case, simple curetting may not be sufficient, and the gouge and mallet may have to be used. To destroy the cochlear nerve, the whole of the cochlea should be removed. This is sometimes a difficult matter to determine. If the operation be done for the relief of tinnitus, then, after as much as possible of the cochlea has been removed, the interior may be swabbed out with strong carbolic acid solution, which should set up sufficient inflammatory reaction to destroy the nerve-terminals.

=Extirpation of the labyrinth.= This consists in the removal of the semicircular canals, and opening of the vestibule and cochlea, the steps of which have already been described in the above operations.

Before the operation is completed, the inner wall of the vestibule and the cochlea should be carefully examined for fistulæ, and in order to see if any pus enters these cavities from within. If this be the case it means that, in addition to labyrinthine suppuration, there is presumably an extra-dural abscess of the posterior intracranial fossa, drainage of which is essential in order to obtain a recovery.

After the operation has been completed, the cavity should be filled with hydrogen peroxide, then gently syringed out with weak biniodide solution, and finally dried and lightly packed with sterilized gauze.

Even although the operation may have been performed in a non-suppurative case, it is wiser to leave the posterior wound open for the first few days in order to permit of free drainage.

=After-treatment.= If the suppuration has been limited to the internal ear, a successful result may be expected if the symptoms subside rapidly as a result of the operation. If there be complete destruction of the labyrinth before operation its performance should give rise to no symptoms of shock nor further disturbance of equilibrium.

In the majority of cases, however, owing to the nerve-terminals being still in a state of activity, the irritation set up as a result of the operation may cause increased attacks of nystagmus, vertigo, and vomiting. The vomiting is the first symptom to disappear, and then the nystagmus; but complete recovery of equilibrium may not occur for a considerable period, during which time the patient, though otherwise well, may still have a slightly staggering gait.

If the operation has been limited to the external semicircular canal, and the hearing power still exists, the after-treatment should be carried out as already described in the complete mastoid operation. If, on the other hand, the cochlea has been interfered with, or if it be certain that there is no longer any hearing power, then there is no object in trying to preserve the patency of the tympanic cavity, which in this case may be allowed to granulate up from its depth like an ordinary surgical wound.

The immediate anxiety of the surgeon after the operation is the possible onset of meningitis or the presence of a cerebellar abscess, which will necessitate further operation unless otherwise contra-indicated (see p. 460).

=Comparison of the operations.= Opening of the vestibule above the facial nerve is limited to those cases in which the lesion is situated within the semicircular canals and to the posterior portion of the vestibule; that is, either in non-suppurative cases in which the operation is performed in the hope of curing vertigo, or in suppurative cases in which the function of hearing still exists.

Opening of the vestibule below the facial nerve is to be preferred as a rule, especially if the function of hearing is already destroyed, because it permits of drainage from the inferior part of the vestibule; in addition, by working forwards, the outer wall of the cochlea can be removed and any disease within it can be tracked out to its limits.

If there be suppuration within the cochlea, sufficient drainage will not be obtained by merely opening the vestibule through the semicircular canals, but the cochlea itself must be opened. Again, if the lower portion of the vestibule and cochlea be first explored and found filled with purulent secretion, it is wiser to complete the operation by also opening the vestibule from above,--that is, to completely extirpate the labyrinth, which is now functionally useless and almost certain to be infected throughout its whole extent.

=Intracranial complications.= If, in addition to the labyrinthine suppuration, intracranial suppuration be suspected, the labyrinth should be explored first; but when possible the operation should be arrested at this point to see if the symptoms subside. If they continue, the exploration of the intracranial cavity can then take place through the internal ear, after a delay of twenty-four hours or more.

Of the intracranial complications, meningitis is most frequent, and next in order cerebellar abscess. In addition, thrombosis of the bulb of the jugular vein may take place from infection through one of the smaller tributary veins; or a localized extra-dural abscess may be found situated along the posterior portion of the petrous bone in consequence of direct extension of the infection through the internal auditory meatus, or as a result of empyema of the endolymphatic sac. This latter condition is almost impossible to diagnose, but may be discovered accidentally if the vestibule is opened by the posterior route according to Neumann’s method.

=Difficulties.= The chief difficulties are anatomical, and the inability to obtain a clear view owing to general oozing of blood.

The first is generally due to insufficient removal of bone; the second can usually be controlled by means of good assistants and the frequent employment of hydrogen peroxide or of adrenalin solution.

=Dangers.= Injury to the facial nerve. This, as might be expected, is not infrequent. If a burr be used, the nerve may be completely torn across and permanent paralysis may result. If, however, the gouge and mallet be employed, complete recovery usually takes place, as the injury seldom consists in complete destruction of the nerve.

Opening up of the internal meatus. This may be accompanied by a gush of cerebro-spinal fluid. There is nothing to be done except to try and keep the part as clean as possible and see that there is free drainage. Undoubtedly, as a result of this mishap, death has afterwards occurred in consequence of septic meningitis.

Injury to the internal carotid or bulb of the jugular vein. These are possibilities which, however, should not occur if ordinary care is taken.

=Prognosis.= The prognosis of labyrinthine suppuration is always grave, owing to the frequency of intracranial complications.

The most favourable cases are those in which the disease is localized and is of chronic duration. The most unfavourable are those in which acute suppurative labyrinthitis is accompanied by extensive bone disease.

According to statistics, the mortality is about 50% in cases not operated upon. As a result of operation, this has been reduced to less than 20%, and in the majority of these cases the ultimate fatal result cannot be put down to the operation itself. The patient is frequently seen too late, that is, after intracranial complications have already occurred. There is no doubt that the death-rate will diminish proportionately according as the necessity of operating early becomes more and more recognized.

With regard to hearing, extensive operations upon the labyrinth lead to complete deafness; nor, indeed, can recovery of hearing be expected except in those cases in which the disease and operations have been limited to the semicircular canals and to the posterior portion of the vestibule, and even then recovery of hearing is exceptional.

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Chapter VIII

OPERATIONS FOR EXTRA-DURAL ABSCESS AND MENINGITIS OF OTITIC ORIGIN

ON INTRACRANIAL COMPLICATIONS IN GENERAL

As the intracranial complications of otitic origin are due to direct extension of the pyogenic infection through the temporal bone to the cranial cavity, it follows that they will depend on the extent of the disease within the temporal bone, the direction in which it has spread, and the virulence of the infection. For this reason, also, the site of the intracranial lesion is always in close relationship with the area of the diseased bone. Thus, if the infection spreads upwards through the attic and tegmen tympani, it may lead to extra-dural abscess or to meningitis of the middle fossa, or to a temporo-sphenoidal abscess. Similarly, disease of the mastoid cells posteriorly may give rise to a perisinuous abscess, to meningitis of the outer surface of the posterior fossa, to lateral sinus thrombosis, or to a cerebellar abscess situated superficially and involving the outer portion of its lateral lobe just behind the lateral sinus; or caries of the floor of the tympanic cavity may give rise to thrombosis of the jugular bulb; or internal-ear suppuration to an extra-dural abscess occupying the posterior surface of the petrous bone, to meningitis of the posterior fossa, or to an abscess of the cerebellum deeply placed in its anterior inferior angle.

Operation is always imperative unless the patient is seen too late and it is obvious that the condition is hopeless.

Before operation is decided on the following points must be carefully considered: (1) Is it possible that the symptoms simulating the intracranial lesion are due to suppuration still limited to the temporal bone? (2) What is the character of the lesion? and (3) What is its situation?

As a rule, so long as the suppurative process is limited to the middle ear and to the mastoid region, the symptoms are those of a local septic infection. At the same time it must be remembered that in infants and in young children it is not uncommon for retention of pus within the middle ear to produce a clinical picture closely simulating an intracranial suppurative lesion. The ear, therefore, should always be inspected in every case. Sometimes a bulging membrane is discovered or the existing perforation is found to be insufficient for drainage. In such cases the symptoms may subside on free drainage being obtained by the simple act of paracentesis of the tympanic membrane.

If, however, free drainage already exists, the mastoid operation should be performed at once.

If the intracranial symptoms be still somewhat indefinite, and there is no apparent urgency, the intracranial cavity should not be explored immediately unless this is found to be imperative at the time of operation. This can be done later, if the symptoms do not subside.

Although exploration of the intracranial cavity is always urgent when it is certain that an intracranial suppurative lesion is present, yet to explore with a negative result is a grave misfortune, owing to the possibility of infecting the intracranial cavity.

Although the surgeon may be certain that an intracranial lesion is present, yet it may be very difficult to determine its character or whether several lesions coexist. The surgeon must therefore be prepared to act according to what he finds at the time of operation.

Thus, if exploration of the temporo-sphenoidal lobe be negative, and yet the cardinal symptoms point to an intracranial abscess, the cerebellum must also be explored. Again, if the diagnosis of intracranial abscess be doubtful before operation, and if, during the operation, lateral sinus thrombosis be discovered, it is wiser to limit the operation to tying of the jugular vein and removal of the septic thrombus. The bone, however, should be removed above and behind the sinus so as to expose the dura mater covering the temporo-sphenoidal lobe and the cerebellum.

In such cases, if the symptoms of intracranial suppuration still continue, it is an easy matter to explore the temporo-sphenoidal lobe or cerebellum at a subsequent operation.

Although under exceptional circumstances (see p. 461) it may be justifiable to open an intracranial abscess by directly trephining the skull over it, yet free opening of the mastoid process should be the first step in the operation, as the primary focus of the disease exists within the temporal bone. In addition, much information may thus be gained in a doubtful case with regard to the situation of the intracranial lesion.

OPERATIONS FOR EXTRA-DURAL ABSCESS

This is far more common as a sequel of acute than of chronic disease of the mastoid process.

=Indications.= Operative interference is indicated in order to permit of drainage. An extra-dural abscess is frequently discovered accidentally, especially if the surgeon follows out the golden rule to trace any patch of carious bone to its limit. In doing so he may suddenly meet with a gush of purulent discharge coming through an opening in the bone in the region of the tegmen tympani or sigmoid sulcus.

Although an extra-dural abscess may give rise to no special symptoms, the following are suggestive:--

1. If, in spite of opening up the mastoid cells and antrum, pyrexia and headache persist, especially if the headache be localized to the affected side and accompanied by tenderness on pressure above the ear or behind the mastoid process.

2. If, before operation, there be a very profuse discharge from the ear, apparently too copious to come from the tympanic cavity or mastoid antrum.

3. In children an extra-dural abscess may give rise to symptoms of cerebral irritation or compression if it extends upwards from the tegmen tympani along the parietal region; or, if situated in the posterior fossa, to retraction and stiffness of the neck.

Although such symptoms may be also associated with an intracranial abscess or meningitis, yet, if on exploration of the intracranial cavity a large extra-dural abscess be discovered, further operation may be postponed (unless its extension is obviously necessary) until time is given to see whether the symptoms will subside or not.

=Operation.= If the mastoid process has not been opened already, the simple or the complete operation is performed, according to whether the suppuration is recent and acute, or is of long standing.

If, however, this has been done, the wound is reopened, all granulations are curetted away, and the cavity is cleansed and dried.

The antrum and mastoid cavity are then thoroughly examined. If a fistula in the bone already communicates with the abscess, pus may be seen to ooze through it. If not, careful search is made for any carious tract of bone, which is now followed up until the dura mater is reached.

After the pus has drained away more bone is removed so as to expose the dura mater fully over the infected area, which is usually vascular or covered with granulations. The latter, however, should be left severely alone. If the abscess be situated in the middle fossa above the tegmen tympani, the bone is best removed by chiselling upwards until the lower margin of the squamous portion of the temporal bone is reached. Then, with a pair of bone forceps, more bone can be punched away quickly until a sufficient opening is obtained (Fig. 243).

Exploring with the probe and curetting away of granulations should be avoided as far as possible for fear of injuring the sinus. If its wall be already inflamed, it may be torn through, and the resulting hæmorrhage may render the further steps of the operation a matter of extreme difficulty.

Before completion of the operation, a blunt-pointed seeker should be passed round the edge of the opening in the bone to see that its margin is smooth and even, and all sharp edges of bone bordering on the dura mater should be removed. If this precaution be neglected, a splinter may get pressed inwards and injure the dura mater, and thus set up meningitis.

If possible the bone should be removed until the healthy dura mater is reached. If the extent of the abscess prohibits this, its limits, however, should be ascertained. This can be done by pressing the dura mater inwards with a spatula so as to separate it from the overlying bone.

The final step is to irrigate the cavity with warm boric or saline solution and to insert drains of gauze or of fine india-rubber tubing between the dura mater and bone. The wound cavity is then lightly packed with gauze and a simple dry dressing applied.

=After-treatment.= Provided there be no other intracranial symptoms, recovery should be as rapid as in the case of simple inflammation of the mastoid process. In the after-dressings, however, special care should be taken not to press in the gauze roughly or tightly against the still inflamed dura mater, in case of injuring its surface and causing further extension of the pyogenic infection to the meninges or lateral sinus. The dressings should be changed daily. It is sufficient to irrigate the wound with some mild aseptic lotion and afterwards to repack it lightly. If Schwartze’s operation has been performed, the after-treatment is similar to that already described (see p. 387). In the case of the complete operation, after the purulent discharge has practically ceased and the surface of the wound appears healthy, the packing of the cavity may be carried out through the meatus, instead of through the posterior wound, the latter being then allowed to close.

=Intracranial complications.= Infection of the lateral sinus is the most frequent complication, but meningitis, ulceration of the surface of the brain, or intracranial abscess may also occur.

One or more of these complications may already exist at the time of operation, but may not be sufficiently marked to warrant further exploration of the intracranial cavity. It is wiser, therefore, to give a guarded prognosis during the first few days after the operation, not only with regard to recovery, but also to the possibility of further operative procedures becoming necessary.

OPERATIONS FOR MENINGITIS OF OTITIC ORIGIN

Formerly the onset of symptoms of meningitis was a distinct contra-indication to operation. More recently, however, this view has become modified, especially as it has been shown definitely by Macewen, Jansen, Brieger, and others that recovery is possible if operation is undertaken sufficiently early before the inflammation of the cerebral membrane has become diffuse.

In this connexion must be mentioned--(1) Serous meningitis: a name given to an increase of the cerebro-spinal fluid within the subdural or subarachnoid space, or the ventricles, the hypersecretion being probably caused, as Merkens suggests (Deutsche Zeitsch. für Chir., vol. lix), by the toxic infection induced by the suppurative focus in contact with the external surface of the dura mater. The symptoms of serous meningitis may closely simulate an intracranial abscess or a purulent meningitis, except that frequently there is no pyrexia. (2) Purulent meningitis, which may be diffuse or localized. (3) Pseudo-meningitis: that is, a condition simulating meningitis but in reality due to irritation of the meninges as a result of suppuration still confined within the temporal bone--for example, the result of acute middle-ear suppuration in infants.

Clinically it is often difficult to determine before operation which variety is present.

=Indications.= Operation is indicated as soon as the onset of meningitis has been diagnosed and should be performed without delay. Waiting for all the cardinal symptoms of meningitis to occur will never save life. The only possibility of doing so is to operate while the inflammatory process is still localized. At the same time it must be recognized that whenever symptoms of meningitis occur the prognosis is most serious.

Lumbar puncture should always be performed as an aid to diagnosis. If the cerebro-spinal fluid be clear and sterile, diffuse meningitis can usually be excluded, although at the same time it must be remembered that it does not negative a localized meningitis without increased intracranial pressure. Increased flow of cerebro-spinal fluid indicates increased intracranial pressure, perhaps the result of serous meningitis. Slight turbidity suggests early purulent meningitis, especially if bacteria are present, but not necessarily that the case is hopeless. If the fluid be definitely purulent, operation may be considered out of the question; a case, however, has been recorded in which recovery took place.

The value of cytological examination of the fluid is still doubtful. Marked increase of polynuclear cells is said to point to acute and intense inflammation, whereas an abatement of the polynucleosis may be taken as a sign of diminution of the meningeal irritation. With this, increased leucocytosis, increasing as recovery progresses, may be looked upon as a hopeful sign.

If it be obvious that the patient is dying, not only from the local infection but also on account of general septic absorption, operation, of course, is excluded. Similarly, at the present time, post-basic meningitis of infants is rightly deemed inoperable.

=Operation.= Although no set operation can be described, the principles of the operation are to expose the infected area widely so as to allow of free drainage and, at the same time, to relieve intracranial pressure. The extent of the operation will therefore depend largely on what is found during the course of the operation itself.

1. In an infant or young child, if the symptoms develop in the course of an acute otitis media, the tympanic membrane should first be inspected to see if there is sufficient drainage. If not, it should be freely incised, and opening of the antrum and mastoid may be delayed for at least twelve hours.

2. In an adult, immediate exploration of the mastoid and antrum is indicated on the onset of meningeal symptoms, even although they occur during the course of an acute middle-ear suppuration.

If the symptoms of meningitis in these cases be as yet indefinite, and if pus be found under tension within the mastoid cavity, or if an extra-dural abscess exists, the dura mater should not be incised at once, but a delay of twenty-four hours should be advised; in many cases complete recovery will take place. If, however, the symptoms continue, intracranial exploration will be necessary.

3. In chronic middle-ear suppuration, meningitis is usually secondary to, or accompanies, other intracranial complications or internal-ear suppuration, the symptoms of which it may mask.

After performing the mastoid operation any tract of carious bone is followed out to its limits.

According to what he finds, the surgeon may first expose the dura mater covering the lower portion of the middle fossa (Fig. 243), or of the posterior fossa behind and in front of the lateral sinus; these are the usual sites of infection. The removal of bone must be free, in order to get well beyond the limits of the infected area, if possible. The dura mater is incised to the limits of its exposure either crucially or by cutting it through in the form of a large flap.

The dura mater is usually congested, but if an extra-dural abscess or lateral sinus thrombosis be present, it may be thickened and of a leathery appearance; or in the latter case almost gangrenous.

The further steps depend on the conditions met with on incision of the dura mater.

1. In serous meningitis a certain amount of clear fluid may escape and the brain surface may be only slightly congested. After removal of the bone and of the dura mater over the infected area the surface of the brain should be scarified in various directions to make certain that the pia-arachnoid has been incised, and fine drainage tubes should be inserted between the latter and the dura mater. In these cases a hernia seldom occurs, although the brain surface may bulge slightly into the wound.

2. In purulent meningitis the surface of the brain is usually covered with turbid fluid or purulent lymph, which may be localized to the site of the diseased bone, or may have spread from this point to a varying extent over its surface.

If the limit of the infection cannot be reached, in spite of removal of a considerable extent of bone and dura mater, all that can be done is to irrigate the exposed area with warm saline solution and to insert fine drainage tubes between the brain and dura mater, at the same time (as in the case of serous meningitis) incising the meninges in various directions.

3. Purulent lepto-meningitis is usually accompanied by encephalitis. If localized by adhesions an accumulation of pus may occur, forming an abscess on the surface of the brain, which also may be superficially ulcerated or necrosed. If there be intracranial pressure from encephalitis, the brain tissue usually protrudes as a dark, hæmorrhagic friable mass, in which shreds of necrotic brain tissue will be seen. In other cases, if there be no increased intracranial pressure and if the condition be quite localized, no hernia may occur, but the surface of the brain may be rough or eroded.

Any purulent secretion should be removed by irrigation, care being taken not to disturb the brain more than is necessary, so as to diminish the risk of breaking down the surrounding adhesions. A hernia may or may not form immediately. If no hernia takes place, it is wiser to do nothing further; that is, provided sufficient bone and dura mater have been removed to reach the limits of the infected area. Some authorities, however, consider that the necrosed portion of the brain should be curetted out. Although in other parts of the body the removal of necrosed tissue is a proper procedure, yet in the case of the brain there is considerable risk of setting up further œdema or septic cerebritis, the progress of which may have become arrested at the time of the operation.

If the inflamed brain tissue protrudes to an excessive degree during the operation itself, the opening in the skull should be enlarged, if it be not already of considerable magnitude, and the dura mater incised to the full limits of the opening. The protruding mass may then be cleanly excised by means of a scalpel. If, however, the brain tissue continues to prolapse, the wound cavity should be simply cleansed and protected by a dressing of sterilized gauze. If the encephalitis subsides, the hernia will not increase in size, and if the wound cavity be kept aseptic, it may gradually shrink.

=After-treatment.= This consists in covering the wound surface lightly with gauze so as to permit of free drainage, and changing the dressing as often as may be necessary.

In serous meningitis a large quantity of cerebro-spinal fluid may escape, and the dressings must be changed frequently. If recovery be going to take place, the temperature gradually becomes normal and the symptoms of meningitis disappear. In involvement of the posterior fossa, the head retraction gradually diminishes and after a few days free movement is noticed. Adhesions form rapidly, binding together the surface of the brain, meninges, and the overlying bone. For this reason the drainage tubes, already inserted between the dura mater and brain, can be removed within a day or two. The exposed dura mater usually becomes covered with granulations from which a certain amount of purulent discharge may be secreted. The duration of the after-treatment depends on the extent of the operation and the size of the wound. Eventually the skin flaps grow together and cover the brain, which afterwards may be felt pulsating through the scar. In these cases it is usually necessary to provide the patient with some protection, such as an aluminium plate.

If, however, a hernia forms and gradually increases in size, the brain should be explored again to see if another abscess can be discovered; or the lateral ventricle itself may be tapped in case of it being distended with fluid. Both these operations, however, must be looked upon as extreme measures.

If the patient otherwise recovers and a hernia still persists, the question arises what to do. Conservative treatment should first be employed, aseptic dressings being maintained, and slight pressure applied with compresses soaked in rectified spirits. If these measures fail, then the projecting portion of the hernia may be excised (see Vol. III).

=Other methods.= In addition, the following methods of treatment have been suggested. Although many failures have occurred in proportion to the few successful cases published, yet they show the possibility that something can be done by operative measures, and that considerable advance has been made in recent years in this direction.

(i) =Repeated lumbar puncture.= In a few cases of serous meningitis this has proved successful in that it has relieved intracranial pressure. It is, however, only of value if free communication still exists between the spinal theca and subarachnoid space.

(ii) =Continuous drainage from the spinal canal.= Friedrich, of Kiel, has suggested a counter-opening in the spinal canal by means of laminectomy in order to permit of drainage of the entire dural sac.

(iii) =Puncture of the lateral ventricle.= The temporo-sphenoidal lobe is pierced with a trocar, just above the zygomatic ridge, until the ventricle is reached; this has been performed frequently in order to relieve intracranial pressure. I know of only one recorded instance in which recovery has taken place in spite of there being pyogenic infection of the lateral ventricle; a fact which was proved by tapping the ventricle and removing from it a drachm and a half of purulent fluid (Archives of Otology, vol. xxxv, p. 535).

(iv) =Drainage through the internal ear.= West and Scott have recently described a case of meningitis which occurred after having curetted the inner wall of the tympanic cavity. They then opened up the labyrinth and inserted a wire drain through the internal auditory meatus, at the same time making a counter-opening in the lumbar region, through which they drained the spinal canal. The patient, a child, ultimately recovered.

=Prognosis and after-results.= Unless saved by operation, meningitis is almost uniformly fatal. Even if the patient recovers, whether as the result of operation or not, deaf-mutism or mental deficiency frequently occurs. In a few cases, however, complete recovery has taken place.

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IX. OPERATIONS FOR LATERAL SINUS THROMBOSIS OF OTITIC ORIGIN

GENERAL CONSIDERATIONS

The sigmoid portion of the lateral sinus is the part usually infected. Thrombosis, however, may occur primarily in the region of the jugular bulb from direct extension of the pyogenic infection through the floor of the tympanic cavity; this, though less frequent than involvement of the sigmoid sinus, is not so rare as has hitherto been supposed.

Operative treatment is imperative as soon as septic thrombosis of the sinus has been diagnosed. This, however, is not always an easy matter. Sometimes, indeed, there are no clinical symptoms, the condition perhaps only being discovered whilst performing the complete mastoid operation as a prophylactic measure. The sinus is generally exposed accidentally whilst following out a tract of carious bone, and, to the surprise of the surgeon, pus or granulations may be seen to exude or protrude from an opening in its outer wall. On further exposure of the sinus on each side of the thrombus, the dura mater may appear to be of a dark colour for a short distance, but beyond this to be of normal appearance.

Seeing that there are no symptoms, the presumption is that the sinus is occluded on each side of the septic thrombus by a non-infective clot. It is, therefore, sufficient in such cases to simply excise the sinus wall over the septic area. If the case be so treated, it is essential that the sinus should only be curetted gently over the exposed opening, but otherwise left undisturbed. Also this limited operation should only be performed if the surgeon is satisfied that the septic focus is surrounded on each side by an organized normal clot--the condition in fact being treated as a simple abscess.

To secure free drainage, only the depth of the mastoid wound should be packed with gauze, the surface being protected by a simple dry dressing. The after-treatment is the same as that already described for the complete mastoid operation in which the posterior wound has been left open.

In other cases, if there be an acute inflammation of the mastoid process and if only one rigor has occurred, it may not necessarily mean that thrombosis of the sinus has taken place, as the rigor may be due simply to septic absorption. In such cases it is justifiable to delay opening the sinus if it is found to be exposed within the wound cavity and to be covered with granulations.

The bone, however, should be freely removed until the normal dura mater is reached, and the cavity afterwards rendered as aseptic as possible by syringing it out with hydrogen peroxide lotion. In a large proportion of cases a favourable result occurs, the pyrexia and head symptoms disappearing and an uneventful recovery taking place. On the other hand, gradually increasing pyrexia or a sudden rigor may occur, perhaps not until ten days or so after the primary operation, showing that the sinus has become infected after all. It should then be opened at once, but before doing so the jugular vein should be tied (see p. 448).

In a typical case, however, there is a history of repeated rigors, and in addition there may be attacks of vomiting and headache localized to the affected side, with pain and tenderness on pressure behind the mastoid process, and optic neuritis. In the more severe cases there may also be evidence of thrombosis of the jugular vein or cavernous sinus. It must, however, be remembered that a high and intermittent pyrexia, especially in children, may take the place of rigors. The principles of surgical treatment are to expose the sinus and remove the infective clot completely.

In connexion with this operation two points cannot be impressed too forcibly on the reader:--

1. The operation must be performed at once. The greater the experience of the surgeon the more he realizes that expectant treatment is nearly always fatal, and that a successful result depends largely on early and complete operative measures.

2. Before the sinus is interfered with in any way it is essential to obliterate its lumen below the thrombus in order to prevent any portion of it being swept into the circulation during its removal.

EXPOSURE OF THE LATERAL SINUS

=Indications.= (i) In doubtful cases to decide whether thrombosis exists or not.

(ii) As a preliminary to opening the sinus with or without ligature of the jugular vein.

=Operation.= The first step is to perform the complete mastoid operation, except in the case of acute inflammation of the mastoid process, when Schwartze’s operation will be sufficient.

To expose the field of operation more freely, an incision an inch or more in length is made horizontally backwards, beginning at the mid-point of the posterior margin of the primary incision (Fig. 216), the soft parts being reflected upwards and downwards from the bone, and the flaps so formed being then retracted. Above, the bone should be exposed beyond the level of Reid’s base-line, which roughly corresponds to the line of the transverse sinus; below, the tip of the mastoid should be cleared until the mastoid vein is reached. If it be thrombosed it may be assumed that the lower part of the lateral sinus is also thrombosed. Bleeding from the bone at this point may be arrested by temporarily plugging the foramen with a fragment of sterilized wax.

The condition found on opening the mastoid process varies considerably. If the result of acute inflammation of the mastoid process, the mastoid cells surrounding the sigmoid sinus usually contain pus or granulations, on removal of which a fistula may be seen to communicate with the outer wall of the sinus; or the bone around the sigmoid groove may already be destroyed, with free exposure of the sinus within the wound. With this there is frequently an extra-dural abscess. In other cases, if the infective process has been very virulent, evil-smelling pus, sometimes intermixed with bubbles of gas, may escape on chiselling through the mastoid cortex. This is a sure sign of extensive disease, the sinus wall often being gangrenous and the bone surrounding it necrosed and discoloured.

If occurring in the course of a chronic middle-ear suppuration, very little disease of the mastoid process may be found except along the path by which the infection has spread.

After the sinus wall has been reached, sufficient bone should be removed to expose its outer surface for at least half an inch above and below the supposed infected area.

The decision as to whether thrombosis exists or not may have to be made during the operation itself, and is based partly on the appearance of the sinus wall and partly on the symptoms, the relative value of each varying in each individual case.

Normally the sinus pulsates and is of a bluish-grey colour. If thrombosed, the wall of the sinus may be of a yellow or dark colour and may not pulsate, but neither discoloration nor the absence of pulsation is an absolutely reliable sign of thrombosis. Again, if the sinus be covered with granulations or purulent lymph, it is sometimes impossible to say whether it is thrombosed or not, especially if the clot is limited and parietal. Further, the thrombus may be situated low down towards the jugular bulb, so that if it has not extended very far upwards the exposed portion of the lateral sinus may still be normal in appearance. Palpation of the sinus with the finger or aspiration with a hollow needle is sometimes advised as an aid to diagnosis. These procedures, however, are extremely unwise, owing to the risk of dislodging a small fragment of the infected clot, which may easily occur if the latter does not obliterate the sinus completely. As a means of diagnosis the withdrawal of blood by the aspirating needle is of no value, as it does not negative the presence of a parietal thrombus, owing to the possibility of the needle passing through it into the free lumen of the sinus.

OPENING OF THE LATERAL SINUS

=Indications.= The sinus should always be opened as soon as it is certain that septic thrombosis has occurred.

=Contra-indications.= The only contra-indication for opening the sinus and removing the thrombus is the certainty that either the patient’s general condition will not permit of the operation being performed, or that the septic thrombosis has spread beyond the region from which it is possible to remove it.

For this reason, operation is unjustifiable if the patient is already suffering from septic pneumonia, pericarditis, or acute septicæmia; or, on the other hand, if there are symptoms of cavernous sinus thrombosis on both sides, or general meningitis. If, however, the patient’s general condition be good, operation may be attempted as a last resource even although a pulmonary empyema or a one-sided cavernous sinus thrombosis already exists.

=Operation.= After exposure of the lateral sinus, the next point to determine is the site and extent of the infected area (Fig. 244). On this will depend whether it will be necessary or not to tie the jugular vein in the neck.

The sinus is first exposed towards the jugular fossa until its surface appears normal for at least half an inch. It is wiser, however, always to expose the sinus as low down as possible. A strip of sterilized gauze is then pressed in between the bone and the outer wall of the sinus so as to obliterate its lumen at this spot. Instead of removing the bone from above downwards, the sinus may be exposed first at its lowest limit by chiselling directly through the tip of the mastoid process. In this way it can be obliterated by a strip of gauze before attacking the area of infection. The overlying bone is afterwards removed from below upwards until the thrombosed area is reached.

In removal of the bone from above downwards there is a certain risk of small particles of clot being dislodged into the circulation, or, if the sinus wall is injured, of hæmorrhage taking place if the thrombus at this particular point does not completely occlude the sinus. If, however, the sinus be first exposed and obliterated at its lowest limit, these risks are greatly minimized. There is no special technique in removing the bone beyond that already given in the description of the complete mastoid operation.

The next step is to expose the lateral sinus behind the infected area and follow it backwards until the dura mater appears normal for at least three-quarters of an inch. If necessary, the skin incision must be prolonged still farther backwards, in order to permit of removal of the bone overlying the transverse sinus, which may, perhaps, have to be exposed even to the torcular Herophili.

In removing the bone overlying the infected thrombus, the gouge and chisel should be used rather than the bone forceps or burr. With the latter there is greater risk of dislodging particles of clot into the circulation, owing to pressure of the instrument on the sinus wall.

After the sinus has been exposed well beyond the region of the thrombus, the bone forceps may safely be used, especially in exposure of the transverse sinus; and this is a much more rapid method than removing the bone by means of the gouge and mallet. To prevent the inner blade of the forceps from nipping the sinus wall between it and the bone, the dura mater forming the outer wall of the sinus should be separated from the overlying bone by means of a dura mater separator. In the region of the infected area the sinus wall may be adherent to the bony wall as a result of the inflammatory adhesions, and, in addition, may be extremely friable and so easily torn through.

In exposure of the sinus two points should be remembered: firstly, that it is sometimes difficult to differentiate it from the dura mater covering the temporo-sphenoidal lobe above and the cerebellum below; and secondly, that the transverse sinus is a very much broader vessel than is imagined, being even half an inch in width. Not much force is required to obliterate its lumen, but care must be taken to pack the gauze evenly across its whole width.

After the sinus has been occluded above and below the area of infection, it should be incised with a small knife along its whole length between the obstructing plugs of gauze (Fig. 245). If there be bleeding, it may be due to the sinus being obliterated incompletely, or it may come from the superior petrosal sinus. To find out where the bleeding comes from, the finger should be pressed upon the sinus at its upper and lower limits, close to the obstructing plugs of gauze. If the bleeding stops, it shows that the sinus has not been obliterated completely; this can now be done by further plugging with gauze. If, in spite of this, bleeding still continues, it presumably comes from the petrosal sinus.

All clot and granulations are now rapidly curetted out and the lateral sinus plugged with gauze. After a moment the gauze is withdrawn and another small piece is pressed into the lateral sinus at the point of entrance of the petrosal sinus. After the bleeding has been arrested, the outer wall of the lateral sinus is excised by cutting it away with blunt-pointed scissors. The interior of the sinus is then inspected, special attention being given to the lower portion to see if its lining is normal. If this be not the case, even if there be no signs of thrombosis, it means that the surgeon has failed to get well below the infected area, and therefore the internal jugular vein must be ligatured. If, however, it be normal, the gauze plug already placed between the sinus wall and the overlying bone is left undisturbed.

If there be no bleeding from the sinus (excepting a slight amount from the blood contained within the isolated portion), the thrombus is curetted out and the inner surface of the sinus inspected. After excising the outer wall, search is made for the superior petrosal sinus, which presumably is thrombosed, although perhaps only by normal clot. To expose this tributary, which enters the lateral sinus at the point at which it turns downwards to form the sigmoid sinus, bone must be removed in front of the lateral sinus along the angle forming the roof and inner wall of the mastoid and antrum; that is, along the superior margin of the petrosal bone. If the inner surface of the lateral sinus in its neighbourhood be normal, nothing need be done. If, however, the sinus wall be infected, the petrosal sinus should be followed out, if possible, its outer wall being incised and the clot removed, bleeding being afterwards arrested by pressure.

As a final step, the gauze plugging which still obliterates the lumen of the sinus in its upper part is removed. If the sinus be normal at this point, free hæmorrhage will occur; this is arrested at once by again introducing a strip of gauze between the sinus and the bone. Although during the earlier stages of the operation the inner lining of the posterior portion of the sinus may have seemed to be normal, yet it occasionally happens that hæmorrhage does not at once occur on removing the plug of gauze; but after a moment or two a long smooth clot, gradually tapering at its end, may be shot out from the opening within the sinus, being followed by a gush of blood. The terminal portion of this clot is non-infective and of recent formation. Its appearance is always a matter of satisfaction, as it means that the sinus has been freely exposed and opened behind the infected area.

If on exposure of the sinus it be found that the clot extends so low down that it will be impossible to obliterate the sinus well below the infected area, the jugular vein should be ligatured at once before interfering further with the sinus from the mastoid wound.

Attempts to remove the clot from the jugular bulb by curetting out the sinus from above are only referred to to be condemned. The surgeon who believes in this method hopes that all the infected portion of the clot will be swept out by the flow of blood. It is not, however, always possible to introduce a curette into the jugular fossa, and if the clot extends beyond this region it cannot be curetted away completely. The result of the operation does not depend so much on the skill of the surgeon as on whether the terminal portion of the clot be infected or not. Recovery is most likely to take place if a non-infective clot already extends beyond the region of the curette and so obliterates by natural means the lumen of the vein below the point reached by the surgeon. If, on the other hand, free hæmorrhage occurs as a result of the curetting, it means that the lumen of the vein has been restored, but there is no guarantee that all the clot has been completely removed. If any infective portion remains, a fatal result will almost certainly occur eventually as the result of pyæmia.

LIGATURE OF THE JUGULAR VEIN

=Indications.= Unfortunately, opinion is not unanimous with regard to this matter. The chief arguments raised against ligature of the jugular vein are: (1) That it favours extension of the thrombus along the veins communicating with it, especially along the inferior petrosal and condyloid veins, which enter the jugular bulb. (2) That it in no way prevents the spread of infection along other paths, owing to the freedom with which its tributaries communicate with one another. (3) As a result of obstruction in the circulation, acute inflammation of the cerebellum may take place.

Since the jugular vein should only be ligatured if the symptoms point to the onset of a general infection of the circulation and if it be found impossible at the time of operation to obliterate the sinus below the infected thrombus, and since this vein is the chief route by which this infection takes place, it seems a matter of common sense that it should be ligatured. At the same time, as many as possible of its tributaries above the point of ligature should also be ligatured well beyond the point at which they may be thrombosed.

Although extension of the infection may take place along other veins after ligature of the jugular vein, it is impossible to say whether the result is post or propter hoc. Against ligature, statistics have been quoted to show that in a series of cases in which the jugular vein has not been tied the percentage of recoveries is just as high as in those in which it had been ligatured. This argument is not quite sound, because there is no doubt that in the cases in which ligature of the jugular vein is justified the chances of recovery, owing to the extension of the thrombus downwards, must be less than in the less serious cases in which it is admittedly unnecessary to tie the vein. It is also impossible to say how many cases would otherwise have ended fatally if ligature had not been performed.

In the majority of cases the vein is ligatured after exploration of the lateral sinus. In a few cases, however, the symptoms warrant it being performed as a primary step of the operation, even before the mastoid process has been opened.

=After exposure of the lateral sinus.= (i) If the clot extends so low down that it is impossible to obliterate the lumen of the sinus below its lower limit.

(ii) If there be thrombosis of the bulb of the jugular vein. This condition is sometimes difficult to diagnose. There may be no symptoms excepting, perhaps, rigors occurring during the course of chronic middle-ear suppuration, as even the lower portion of the sinus may be quite normal in appearance owing to the clot being limited entirely to the jugular bulb. The probability of the diagnosis being correct is strengthened by the presence of granulations or carious bone on the floor of the tympanic cavity. It is better to risk tying a normal vein than to fail to tie one already infected.

(iii) If the sinus was obliterated above the jugular bulb at the primary operation and rigors occur subsequently, showing that the sinus is infected still lower down.

=Before exposure of the lateral sinus.= (i) If there be thrombosis of the jugular vein. In addition to the ordinary signs of lateral sinus thrombosis, there may also be infiltration of the tissues, or tenderness along the anterior border of the sterno-mastoid muscle. The prevalent idea that a thrombosed jugular vein can be felt on palpation as a hard cord extending down the neck is erroneous. If anything be felt it is probably some enlarged cervical glands lying along the line of the vein. In any case it is bad practice to palpate the internal jugular, as by doing so there is considerable risk of dislodging particles of the septic clot.

(ii) If, as a result of septic infection, the general condition of the patient be so serious that a prolonged operation seems unjustifiable. In such cases, the lateral sinus is rapidly exposed and incised after tying the internal jugular, its contents are curetted out and the wound cavity lightly plugged; the completion of the operation, consisting of the opening up of the mastoid cells and antrum, and possibly also exploration of the intracranial cavity, may be performed next day or later.

(iii) If it be doubtful whether septic thrombosis of the sinus has already occurred, it is justifiable in certain cases merely to expose the sinus freely and not to open it (see p. 440). If rigors subsequently occur in these cases and it becomes evident that the sinus has become infected after all, then it is wiser to tie the jugular vein as a primary step of the operation before opening up the sinus itself.

The writer’s reason for doing so is, that at the second operation he has always found the clot to be extensive, or, at any rate, to be situated so low down as to prevent the sinus being obliterated below the infected area.

=Operation.= Formerly it was considered sufficient to divide the vein between two ligatures and to leave it in situ. Now, however, the upper portion of the vein is brought out through the wound in the neck after this has been done.

The patient lies in the recumbent position with the affected side close to the edge of the table. The head and shoulders should rest on a hard pillow in such a fashion that the neck is slightly extended, the chin being drawn upwards and the head turned a little to the opposite side so that the anterior border of the sterno-mastoid muscle can be clearly defined throughout its whole length. The surgeon stands at the side to be operated on. The neck is carefully cleansed, but in doing so care should be taken not to rub the neck too violently, nor should any attempt be made to palpate the line of the jugular vein in the hope of feeling it. There is no object in doing so, and if it is thrombosed a portion of the clot may be dislodged.

An incision, at least three inches in length, is made along the anterior border of the sterno-mastoid muscle, the mid-point of the incision corresponding to about the level of the cricoid cartilage. On cutting through the skin and platysma some small veins may be met with: they should be clamped with forceps and divided. If, however, the anterior jugular vein be exposed, it should be drawn to one side, if possible, and not divided. The anterior border of the sterno-mastoid muscle is clearly defined, until the upper border of the omo-hyoid muscle is reached (Fig. 246). Its edge is then drawn slightly outwards by means of a retractor and separated from the underlying deep fascia. Beneath this fascia is the carotid sheath, which encloses not only the carotid artery but the internal jugular vein and the vagus nerve. The vein is external and somewhat superficial to the artery, and the vagus nerve lies behind. A vein of varying size will be seen crossing obliquely downwards and outwards to pierce the deep fascia at a level corresponding to the cornua of the hyoid bone; this is the common facial vein about to enter the internal jugular (Fig. 247). If the surgeon has not had much experience and has difficulty in finding the jugular vein, a certain method of doing so is to find the facial vein and then follow it down until it enters the jugular. The carotid sheath should be opened about this point, and the position of the vein ascertained by feeling the pulsations of the carotid artery. The sheath of fascia covering the jugular vein is picked up with a pair of fine forceps and cut through with a sharp scalpel, which should be inclined obliquely outwards so that the flat of the knife is held towards the vessel. Any enlarged lymphatic glands lying over the vein must be removed.

When the vein has been identified, a blunt dissector is passed between its outer wall and the sheath, so as to separate the two. The sheath is incised upwards and downwards until the vein is freely exposed. If the vein be patent, it will be of a bluish colour, expanding and diminishing in volume with each act of respiration. If it be thrombosed, there is usually accompanying periphlebitis which may make the separation of the sheath from the vein and the surrounding tissues difficult. If there be no periphlebitis, the thrombosed portion may be purplish, or, if the clot be of long standing and breaking down, more of a yellowish colour; the vein stands out as a cord and does not pulsate. If the thrombus be limited to the portion above the entrance of the common facial vein, the upper portion of the jugular may be small and collapsed, only becoming full and pulsating below the point at which the facial joins it.

The next step in the operation is to get well below the point at which the jugular is thrombosed. If the thrombus be practically limited to the jugular fossa the vein may be ligatured above the common facial; if not, as low down the neck as possible. In ligaturing the vein low down in the neck, the skin incision must be extended downwards, and as the lower portion of the neck is reached, the omo-hyoid will have to be pulled aside. The probe should be passed all round the vein so as to make certain that it is freed from its sheath, and especially that it is separated from the vagus nerve which lies behind it.

An aneurysm needle threaded with silk is now passed around the vein from within outwards. The loop of silk is cut so as to form two ligatures, and the aneurysm needle then withdrawn; the lower ligature is first tied, its ends being cut short. The upper ligature is then tied a short distance above it, but in this case the ends are left long. The vein is raised from its bed by slight traction on this ligature and is cut across between the two, the lower portion being allowed to sink back into the wound. The upper portion is then carefully separated for some distance upwards. Lying behind the vein may be seen the vagus nerve (Fig. 248). Any tributaries are clamped between two forceps, cut across, and ligatured, the upper end of the vein being brought out into the upper angle of the wound. Care must be taken that enough of the vein is dissected out to allow of this being done, especially if the ligature is applied above the level of the common facial; in this case the facial need not be tied.

If there be no periphlebitis, inflammation of the soft tissues, or thrombosis of the vein itself in the neck, the wound may be closed by means of silkworm-gut sutures, excepting at its upper angle through which the open end of the jugular vein projects. If, however, the vein be thrombosed, and especially if there be periphlebitis, the wound should be left open, except perhaps at its lower angle, and should be lightly packed with gauze, as in these cases cellulitis of the neck may afterwards occur.

After completion of the operation in the neck the surgeon turns to the mastoid process. If the ligature of the vein has been the primary step, the mastoid operation is now performed and the lateral sinus is freely exposed for a considerable distance behind the thrombus. If, however, the mastoid operation has been the first stage, and the jugular has been tied as soon as exposure of the sinus showed it to be thrombosed, the operation on the mastoid is now completed and the sinus opened as already described (see p. 444). The next step is to incise the sinus freely from above downwards towards the jugular fossa and curette out the thrombus.

If there be considerable hæmorrhage, it means that the thrombus is probably parietal and situated within the jugular bulb, the bleeding presumably coming from the inferior petrosal sinus or other tributaries which enter the bulb or upper portion of the jugular vein. If the bleeding be excessive, the sinus is plugged after a moment or two, by inserting a piece of gauze into its lumen towards the jugular bulb.

In this case the portion of the vein brought into the neck is usually also filled with blood. After isolating it from the deeper tissues by packing strips of gauze round it, the vein is deliberately opened just above the ligature. The bleeding usually stops after a moment or two, but if it cannot be controlled, the lumen of the vein must again be closed by a ligature, the end of the vein being allowed to project on to the neck.

If there be no bleeding from the lower portion of the lateral sinus and jugular bulb, it means that the vessel is completely thrombosed at this point. The clot should now be removed by curetting through the sinus from above downwards towards the jugular bulb, and also from below upwards through the open end of the jugular vein.

The venous channel is afterwards syringed through from above downwards. To do this, a piece of rubber tubing is inserted into the opening in the lateral sinus and some warm saline solution is injected through it with a syringe. If the clot be not firmly adherent it can usually be washed out through the opening in the vein. No force should be used. If gentle syringing be not sufficient to expel the clot, the attempt must be given up. The chief objection against syringing is the possibility of particles of the septic thrombus being forced into the veins communicating with the jugular bulb. A small drainage tube is inserted within the sinus.

In order to keep the lumen of the vein in the neck open, it should be stitched to the edge of the wound surface by several catgut sutures (Fig. 250). If the bleeding necessitated plugging of the lower end of the sinus and retention of a ligature on the vein in the first instance, syringing should be postponed until the first dressing; the portion of the vein left protruding through the skin wound in the neck is then cut across, and the edge of the vein sutured to the margin of the wound under cocaine.

The mastoid cavity is lightly plugged with gauze and a dry dressing applied. The wound in the neck is similarly treated.

=After-treatment and progress of the case.= There is frequently considerable shock after the operation, especially if exposure of the jugular bulb has been undertaken, partly owing to the duration of the operation and to hæmorrhage. If the patient be very collapsed, a continuous saline injection, to which some brandy may be added, may be given per rectum according to Moynihan’s method. After the primary shock has passed off, the immediate result is usually satisfactory.

If the jugular vein has not been ligatured, the first dressing should be performed within forty-eight hours, the gauze packing being removed, the wound syringed out, and afterwards repacked. The plugs of gauze, which were pressed in between the outer wall of the sinus and the overlying bone in order to obliterate the lumen of the latter, should not be interfered with for at least six days. If the case progresses favourably, the temperature becomes normal within a day or two, the patient feels well, and the wound assumes a healthy appearance. If, on removal of the gauze plugging, hæmorrhage takes place, then the plugging must be renewed and not touched again for three or four days. After it is possible to remove these plugs, the wound is treated as has already been described in Schwartze’s operation or in the complete operation in which the posterior wound was left open.

If the jugular vein has been ligatured, the sinus and vein should be syringed through daily, and this should only be stopped after all secretion has ceased, usually a matter of a week or ten days.

When the sinus, jugular bulb, and vein have been exposed throughout their length the wound is treated as an ordinary surgical one, being packed until it granulates up from the bottom (vide infra).

Apart from intracranial and pyæmic complications, the progress of the case may be delayed owing to the enfeebled and septic condition of the patient, and also from the occurrence of abscesses in the neck, or region of the mastoid itself. These abscesses are the result of septic thrombosis occurring in some tiny vessel. The first sign of their occurrence is an attack of pyrexia, shortly followed by a painful swelling at the affected spot. Any collection of pus should be drained at once. Although it is quite good practice to close the incision in the neck in a clean case, yet there must be no hesitation to open it up on the slightest sign of it becoming septic.

The case may appear to progress favourably for the first week or ten days, and then an intermittent and increasing pyrexia may occur for no obvious reason. This is usually due to extension of the infection along the petrosal sinuses, or perhaps along the transverse sinus.

Symptoms of involvement of the cavernous sinus may arise, perhaps even with formation of a peri-orbital abscess; or, on the other hand, the patient may gradually sink in consequence of septic toxæmia; or the end may come more suddenly with the onset of basal meningitis. Unfortunately, these cases are almost hopeless from the first, as very little can be done from a surgical point of view owing to the fact that they are not seen soon enough.

In thrombosis of the cavernous sinus the only hope of recovery lies in its exposure and incision of its wall. The sinus may be approached by tracking forwards the superior petrosal sinus--a matter of considerable difficulty, and seldom justifiable. Recently Charles Ballance has suggested the adoption of the Hartley-Krause route for extirpation of the Gasserian ganglion, and says he has found the operation easy and effectual. If pus be evacuated from the sinus he considers it advisable to adopt the recommendation of Voss, who cuts away the zygoma and removes more bone from the basal aspect of the skull so as to get direct drainage (Allbutt and Rolleston’s System of Medicine, 1908, vol. iv, Part ii, p. 495).

EXPOSURE OF THE JUGULAR BULB

This may be performed either by following the sinus downwards or through the floor of the auditory canal and tympanic cavity. The former method was first described by Grunert (Archiv für Ohrenheilkunde, 1902, vol. liii, p. 287); the latter by Piffl (Archiv für Ohrenheilkunde, 1903, vol. lviii, p. 76).

=Indications.= The object of the operation is to remove the septic clot situated within the jugular bulb in the hope of preventing extension of the infection along the veins leading into it, more especially the inferior petrosal sinus. This indeed has been known to occur even after the lateral sinus has been curetted out, the jugular vein ligatured, and the venous channel syringed through.

=Grunert’s operation.= After free opening of the mastoid process and exposure of the outer wall of the lateral sinus, the skin incision is extended downwards beyond the tip of the mastoid. The soft tissues are then separated from the bone forwards and backwards so as to expose completely not only the mastoid process, but also the digastric fossa and base of the skull immediately behind it, up to the outer bony margin of the jugular foramen. Unless care is taken, the forcible traction forwards of the soft tissues necessary to expose the field of operation may injure or tear the facial nerve as it emerges from the stylo-mastoid foramen.

The tip of the mastoid process is removed first. The lateral sinus is then freely exposed to its lowest possible limit by removing the overlying bone. In doing this it must be remembered that the sinus becomes horizontal just before it ends in the jugular fossa, so that at this point the skull forms its floor instead of its outer wall.

After having exposed the sinus as freely as possible, the ‘bridge’ of bone separating it from the outer wall of the jugular foramen is removed in small pieces by nipping it away with narrow biting forceps until the jugular bulb is exposed from its outer surface. The facial nerve should not be injured, as it lies in front and external to the portion of the bone to be removed.

In performing the later stages of the operation, the patient’s head should be turned well over to the opposite side in order to get a good view of the parts lying behind and beneath the mastoid process; and in tracking the sinus downwards, the probe should be used carefully in order to try and define the exact position of the jugular fossa.

=Piffl’s operation.= Owing to the anatomical difficulty of reaching the jugular bulb by following the sigmoid sinus downwards, especially in those cases in which the sinus lies far forwards and in which, at the same time, there is a very well-developed jugular fossa, Piffl recommends exposure of the jugular bulb from above through the auditory canal. The object of this method is to prevent injury to the facial nerve, which he states is almost certain to occur in Grunert’s operation, if carried out in cases such as those just mentioned.

After the complete mastoid operation has been performed, the skin incision is extended downwards and forwards in order that the soft tissues may be freed from the floor and anterior surface of the bony portion of the auditory canal as far forward as the Glaserian fissure. The soft tissues are pulled forward with a blunt hook to give sufficient room. The lower portion of the tip of the mastoid is removed by means of the gouge, as far as can be done without injuring the facial nerve, which in this operation is pulled backwards with the soft tissues at the posterior inferior margin of the wound. The lower bony margin of the auditory canal, now freely exposed, is removed by means of a pair of fine biting forceps until the floor of the tympanic cavity is reached. If there be not sufficient room, the bone may be clipped away as far as the styloid process, which also may be removed by bone-forceps after the muscles attached to it have been dissected off.

In freeing the styloid process, its posterior surface must be approached with caution for fear of injuring the facial nerve, which here lies in close connexion with it. In the front of the wound the capsule of the temporo-maxillary joint may be exposed, but must not be interfered with.

After removal of the styloid process, the uppermost portion of the external jugular vein should be seen emerging from the jugular fossa. This is followed upwards by careful removal of the bone between it and the floor of the auditory canal and tympanic cavity, until the jugular bulb is brought into view. This part of the operation must be proceeded with very cautiously, the bone being nibbled away in small fragments with gouge forceps which are of sufficient strength to nip through the bone without having to wrench it away. The amount of bone to be removed and the difficulty of the operation depend largely on the anatomical condition found.

Whether Grunert’s or Piffl’s operation has been employed, the operation may be completed either by incising the outer wall of the sinus and jugular bulb, then curetting out the thrombus, and finally washing through the lower portion of the vein from above downwards, or by the more radical method of also exposing the upper portion of the jugular vein throughout its whole length. To do this the post-aural incision is continued downwards until it joins the one previously made in the neck. To obtain room, the neck must be somewhat extended and the jaw pulled well forward and the sterno-mastoid muscle backwards. The jugular vein is then dissected upwards towards the bulb.

The nearer the jugular fossa is approached the deeper and more difficult becomes the exposure of the vein. Passing in front of it may be found the stylo-pharyngeal, stylo-hyoid, and digastric muscles. In Grunert’s operation they need not be cut through as the vein will lie posterior to them. In Piffl’s operation these muscles probably have been already reflected forward, after removal of the styloid process.

Particular care must be taken not to injure the nerve trunks, which are in such close relationship with the vein. Lying immediately behind the vein is the vagus nerve; the spinal accessory passes downwards and outwards behind it, and the glosso-pharyngeal and hypoglossal nerves forwards between the vein and the internal carotid artery.

After the vein, the jugular bulb, and the sigmoid sinus have been exposed throughout their course, their outer wall is cut through with a pair of blunt-pointed scissors along its whole length, so as to convert the venous canal into an open gutter. The thrombus is then curetted out and the dissected portion of the jugular vein cut off as high up as possible. Any bleeding from the inferior petrosal sinus or condyloid veins, which may not be thrombosed, should be arrested by direct pressure of a strip of gauze over the bleeding points. The wound cavity is then washed out with a weak biniodide solution and dried.

The lower portion of the incision in the neck may be closed with sutures and a small drainage tube inserted at its lower angle. The upper portion of the wound, now directly continuous with that of the mastoid cavity, is left open and packed lightly with gauze, which is inserted into the remains of the venous channel.

=Comparison of operations for lateral sinus thrombosis.= Except when the thrombus is limited to the upper part of the sigmoid sinus, it is undoubtedly wiser to tie the jugular vein than to be content with curetting out the clot after obstructing the sinus above and below by means of gauze plugs. Exposure of the jugular bulb is so difficult an operation and requires so much time, especially if the whole length of the upper portion of the jugular vein is also dissected out, that it is seldom advisable to perform it; nor will it often be justifiable owing to the condition of the patient, who is seldom strong enough to undergo such a prolonged operation. The records of this particular operation are so few that it is impossible as yet to determine its value.

If the sinus be exposed as low down as possible, and the jugular vein dissected out and brought out into the neck, and the venous channel afterwards syringed through, the chances of recovery should be almost as good as in the case of free exposure of the jugular bulb.

If the inferior petrosal sinus be already infected before the operation, it does not matter whether the operation performed is that of syringing through the jugular bulb or freely exposing it, as in either case the inferior petrosal sinus cannot be followed out.

Curetting of the lower portion of the sinus without previous ligature of the jugular vein should never be done.

=Difficulties and dangers of the operation.= The chief difficulty in these operations is anatomical; the chief danger is hæmorrhage.

If the hæmorrhage be due to accidental tearing of the wall of the sinus in the earlier part of the operation, and if it be impossible to obliterate the sinus below this point by pressing in gauze between its wall and the underlying bone, then the jugular vein should be tied before anything else is done.

Extreme vascularity of the bone is not unusual after ligature of the jugular vein. In these cases the surgeon must rely on the cleverness of the assistants in keeping the field of operation clear by careful swabbing.

In exposure of the jugular vein there may be difficulty in finding the vessel, especially if the cervical glands are enlarged, or if there be matting together of the tissues in consequence of periphlebitis or cellulitis. In these cases the best plan is to identify the common facial vein and then trace it down to its entrance into the jugular vein.

With regard to the sinus, the chief danger is injury of its inner wall whilst curetting out its contents: this may afterwards give rise to meningitis or a cerebellar abscess. Accidental pricking of a non-thrombosed jugular vein may allow of entry of air into the vein and so cause death: this is a catastrophe I have not yet met with. Also, if the operator be careless or inexperienced, he may injure the carotid artery or vagus nerve; in the former case the only thing to do is to ligature the artery above and below the wound.

=Complications.= The chief intracranial complications are meningitis and cerebellar abscess; the former usually from extension of the septic thrombosis along the petrosal sinuses. If, at the time of operation, it be doubtful whether intracranial suppuration already exists or not, the surgeon should content himself with removing the septic thrombus from the sinus and await further symptoms. At the time of the operation, however, sufficient bone should be removed to expose the dura mater over the cerebellum. If, in addition to the clinical symptoms, the appearance of the dura mater, the increased intracranial tension, and the absence of palpation suggest the presence of an abscess, the cerebellum should then be exposed and explored (see p. 467). Before doing this, the wound should be made as aseptic as possible and a fresh set of sterilized instruments used.

The complications resulting from general septic infection are pyæmia and septicæmia.

=Prognosis.= The prognosis depends entirely on whether the septic focus can be completely removed or not. Failure to do this is frequently due to the operation not having been sufficiently extensive. It is a matter of experience that if a second operation has to be performed recovery seldom takes place. For this reason the first operation must be thorough.

If such cases could be operated on in the earliest stage whilst the infective thrombus was still limited, without doubt a higher percentage of recoveries would be obtained. Unfortunately, the surgeon may not be summoned until too late, owing to the seriousness of the condition not having been realized.

In any individual case it is impossible to tell for the first few days after the operation what the ultimate result will be. Without operation a fatal termination is practically certain. As a result of operation about one-third of the cases may be expected to recover.

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X. OPERATIONS FOR INTRACRANIAL ABSCESS OF OTITIC ORIGIN

An intracranial abscess, the result of disease of the temporal bone, is usually situated close to the surface of the brain, and is in close relationship with the diseased area of bone through which the infection has taken place. The actual track of the infection can frequently be traced through the bone to the dura mater and brain substance itself; sometimes, indeed, a fistula is found to pass through the bone and to communicate with the intracranial abscess. On the other hand, though rarely, the surface of the bone to all appearances is normal and there are no adhesions between it and the dura mater and underlying brain substance, and the abscess may be situated deeply within the brain.

With regard to the comparative frequency of temporo-sphenoidal and cerebellar abscess, in 100 cases collected from the records of the London Hospital the writer found that in children under ten years of age temporo-sphenoidal abscess occurred in 87% and cerebellar only in 13%, whereas in adults cerebral abscess occurred in 65% and cerebellar in 35%; and that a cerebral and cerebellar abscess occurred together only in 5% of the cases.

These statistics are practically the same as Körner’s (Die otitischen Erkrankungen des Hirns, der Hirnhäute und der Blutleiter). Ballance, on the other hand, considers cerebellar abscess a more frequent occurrence than temporo-sphenoidal.

Multiple abscesses may be met with, usually the result of pyæmia.

=Indications.= An intracranial abscess must always be opened and drained.

Indications pointing to such a condition are persistent headache, purposeless vomiting, a slow pulse, a subnormal temperature, and optic neuritis. With this there is usually some change in the mental condition, especially in the case of a temporo-sphenoidal abscess. In the early stages there may be attacks of simple forgetfulness or mental aberration, or, on the other hand, that of extreme mental excitement. Owing to the intracranial pressure caused by the increase in size of the abscess, the mental state becomes impaired and the condition known as slow cerebration or the ‘dream state’ may be observed.

It must, however, not be forgotten that the same clinical picture may be produced by other conditions, such as an intracranial tumour: in the case of a middle-ear suppuration, however, an intracranial abscess may be diagnosed unless this can otherwise be excluded.

Before operation is decided on, the site of the lesion must be determined. This can only be done if certain localizing symptoms are present.

In a temporo-sphenoidal abscess, if the cortical region be affected, there may be paralysis or paresis of the opposite side, beginning with the face and then spreading to the arm and leg; or in the opposite order if the internal capsule be involved.

If the left temporo-sphenoidal lobe be the site of the lesion, aphasia may be met with, and if the abscess extends backwards, word-blindness may occur. If the centre of hearing be affected there may be complete deafness of the opposite side owing to its destruction; or tinnitus or hyperacusis if the centre be only irritated by the proximity of the abscess; or if the anterior extremity be involved anosmia or parosmia may be noticed. Another important sign, occurring in conjunction with the above symptoms, is a fixed pupil on the affected side.

In a cerebellar abscess the symptoms are less marked, or may even be absent, so that the abscess may remain undiagnosed during life and only be discovered at the autopsy, which may perhaps have been performed on account of the sudden and unexpected death of the patient from rupture of the abscess itself. In walking, in addition to a peculiar staggering gait, there is a tendency for the patient to direct his course gradually towards the affected side. Lateral nystagmus, if present, is usually directed towards the affected side and has to be differentiated from that due to internal-ear disease. If a cerebellar abscess be associated with a labyrinthine suppuration and the latter is explored by operation, the nystagmus will still remain directed to the affected side. If, however, no cerebellar abscess be present the labyrinthine operation will be followed by nystagmus strongly directed to the opposite side. Optic neuritis and vomiting usually are more severe than in temporo-sphenoidal abscess. Headache, if present, may be referred to the occipital region, and there may also be slight retraction of the neck or pain behind the mastoid region as a result of localized and early meningitis of the posterior fossa. If the abscess be very large, there may be paresis or paralysis of the facial nerve and perhaps also of the upper extremity. The deep reflexes may also be altered, the knee-jerk being frequently absent on the affected side. The patient in the late stage usually lies curled up in bed on the side opposite to the lesion, with the knees flexed.

=Methods of operation.= Two methods may be employed:--

1. Trephining directly over the area of the abscess (rarely necessary).

2. First performing the mastoid operation and then following out the route of infection (usual method).

In the case of middle-ear suppuration, trephining has practically been abandoned, and rightly so, since it has become recognized that the intracranial abscess is due to direct extension of the pyogenic infection from the middle-ear and mastoid cavities.

The only circumstances in which trephining may be advised are--(1) If the diagnosis be certain and the operator has no experience of aural surgery. In a case of emergency he is wiser, perhaps, to trephine and drain the abscess, leaving the mastoid to be dealt with afterwards by someone competent to do so. (2) If, after performing the mastoid operation, the situation of the abscess be doubtful. In order to diminish the risk of infection of the brain by an exploratory puncture which may prove negative, the bone may be trephined a little beyond the mastoid wound, either above or behind, according as a temporo-sphenoidal or cerebellar abscess is suspected. If, however, it be considered advisable to make a fresh opening in the bone beyond the septic wound cavity, the aural surgeon will probably prefer to do so by means of the gouge and bone-forceps, to which he is more accustomed.

Trephining has also been advised if the patient is so ill that a prolonged operation is impossible; or if there is cessation of respiration during the operation itself, which may occur in a cerebellar abscess as a result of pressure on the medullary respiratory centres. To those accustomed to perform the mastoid operation, the opening of this cavity and the necessary removal of bone can be done more rapidly by the gouge or bone-forceps than by the trephine.

For whatever reason trephining is done, it is afterwards essential to perform the mastoid operation and to remove the primary focus of the disease, otherwise one of the fundamental principles of surgery will be neglected.

=Operation.= The preliminary preparation of the patient is the same as for the mastoid operation, only the head should be shaved over a wider area. The exposure of the field of operation is the same whether the brain is explored through a trephine opening or from an extension of the mastoid operation.

In the case of the temporo-sphenoidal lobe, it is necessary to extend the incision behind the auricle vertically upwards for an inch or more (Fig. 252); whereas if the cerebellum has to be explored, an incision is carried backwards at right angles to the post-aural incision, just below its mid-point (Fig. 253). In the former case, on reflecting the soft tissues from the underlying bone, the squamous portion of the temporal bone, immediately above the zygomatic ridge, will be exposed; in the latter, the base of the skull behind and below the mastoid process and lateral sinus will be laid bare.

1. =Trephining.= The trephine used should be three-quarters of an inch to one inch in diameter according as the patient is a child or an adult. Either the hand trephine or Macewen’s improved pattern mounted with a guard may be used. If available, the trephine may be worked by a motor, but in this case it should be remembered that the bone will be pierced more quickly than by the hand instrument.

Trephining for a temporo-sphenoidal abscess. The object of the operation is to expose the lowest portion of the middle fossa just above the roof of the antrum and tympanic cavity. The trephine, therefore, should be placed so that it is situated just above the suprameatal spine, its lowest margin being slightly above the zygomatic ridge (Fig. 251). After the disk of bone has been removed the exploration of the abscess is then carried out.

Trephining for a cerebellar abscess. The point at which the bone is trephined must be behind and below the curve formed by the transverse and sigmoid portion of the lateral sinus; that is, behind the mastoid process and below Reid’s base-line.

If the mastoid operation has not been performed, the centre pin of the trephine should be placed at a point 1-1/4 to 1-1/2 inches behind the centre of the external auditory meatus, and an inch below Reid’s base-line (Fig. 251). If, however, the mastoid has already been opened and the lateral sinus exposed, the trephine should be placed so that its anterior border is just behind the sinus and its upper border well below Reid’s base-line.

2. =After performing the mastoid operation.= If this has been done already, the wound is reopened, and cleansed by filling it with hydrogen peroxide. After gently curetting away any granulations the wound cavity is irrigated and then packed in order to dry it. Under good illumination, careful inspection is made to see if a fistula or a tract of diseased bone extends in any direction. Whether the middle or posterior fossa should first be explored depends not only on the clinical symptoms but also on the condition found on opening the mastoid cavity.

=Opening of a temporo-sphenoidal abscess.= A temporo-sphenoidal abscess may be explored either through its lowest point, that is, through the roof of the antrum and floor of the middle fossa, or through its outer wall just above the zygomatic ridge. To obtain a view of the roof of the antrum and mastoid cavities, the head of the patient should lie almost flat on the operating table and be turned well over to the opposite side. The bony roof of the antrum and mastoid is removed by means of the gouge and mallet, and so expose the dura mater covering the floor of the middle fossa (Fig. 252). If a fistula communicates with the antrum cavity and the middle fossa, the bone surrounding it is first attacked. In removing the bone, it must be remembered that the tegmen tympani is exceedingly thin, and unless care is taken pieces of bone may be pressed inwards on to the overlying dura mater. Sufficient bone should be removed to determine whether the dura mater is normal or not. To do this it may be necessary to chisel away the tegmen tympani outwards until the squamous portion of the temporal bone is reached, after which a pair of bone forceps may be used until a sufficient opening is obtained.

The condition found on examination of the dura mater varies. In many cases it is congested or covered with granulations at the site of the infection, and usually it is adherent to the underlying bone. At other times it seems normal.

Increase of the intracranial pressure, as shown by the bulging outwards of the dura mater, and absence of pulsation are suggestive of an abscess. These signs, however, are not conclusive, as on the one hand increased intracranial pressure may be due to other causes and on the other it is quite possible to have pulsation if the abscess be small and deeply placed.

If an extra-dural abscess be present, the intracranial cavity should not be explored at once unless this is absolutely necessary, but this step of the operation should be delayed for at least twenty-four hours. If, however, immediate operation be necessary, special precautions must be taken to render the part as aseptic as possible, and a fine layer of gauze should be packed between the margin of the bone and the dura mater in order to prevent further infection of the brain or meninges. In an uncomplicated case only sufficient bone should be removed to permit of the insertion of a large drainage tube; that is, the dura mater should not be exposed over a larger area than the size of a shilling.

If there be disease of the tegmen tympani and the symptoms point to a temporo-sphenoidal abscess, the brain should be explored through this opening in the bone (Fig. 252), as the abscess is thus not only drained through its most dependent part, but also through its stalk.

If, however, the diagnosis be doubtful, the temporo-sphenoidal lobe may be explored through a fresh opening, just above the tegmen tympani. This will diminish the risk of septic infection from the mastoid cavity. After the dura mater has been exposed sufficiently a small incision is made in it, taking care to avoid wounding any of the vessels. With a pair of forceps the cut edge of the dura mater is drawn outwards and the incision is prolonged in each direction with a pair of blunt-pointed scissors. Similarly, the dura mater is cut through at right angles to the primary incision, so that four small flaps are made and turned back so as to expose the outer surface of the brain.

As a rule the dura mater, arachnoid, and pia mater are fused together by inflammatory adhesions, so that from a practical point of view they need hardly be considered as separate structures. Similarly, at the site of infection, the point of the so-called stalk of the abscess, the cerebral membranes are adherent to the underlying brain, especially if there has been any localized meningitis. For this reason it is sometimes necessary to peel away the dura mater from the brain, in order to expose the latter.

As a rule, very little fluid escapes: if present in considerable quantity, and if it escapes from between the dura mater and brain, it is an unfavourable sign, as it generally signifies early meningitis.

If meningitis be present, purulent lymph or secretion may be seen on the surface of the brain, either localized or spreading from the site of the infection.

If the intracranial pressure be great, the brain will bulge through the opening in the dura mater. If the abscess be very large and situated superficially, the thin layer of brain substance forming its outer wall may rupture as soon as an opening has been made in the dura mater. Sometimes, indeed, the pus may be seen to ooze through an opening in the dura mater, which may be found to communicate with the abscess cavity.

The next step is to open the abscess. Formerly a trocar and canula were used. This method is no longer in favour for the following reasons:--If the wall of the abscess cavity be very thick, it may not be pierced; secondly, the trocar may pass through the abscess cavity and enter the brain substance beyond without draining it; and thirdly, even if the trocar enters the abscess cavity the pus may be so thick as to plug its lumen. For these reasons a fine pair of Lister’s sinus-forceps or a narrow-bladed bistoury is recommended. In the ordinary case Lister’s forceps can be used.

The direction in which the brain is explored depends upon the point at which this is done. Thus, if the procedure be carried out through the tegmen tympani, the brain is explored in an upward direction. The forceps are made to pierce the brain for about an inch; the blades are then slightly dilated and the forceps partly withdrawn. If a large abscess exists, the cavity is usually opened at once and pus flows out along the track of the forceps. If the abscess be small and deeply placed, its cavity may not be entered on the first thrust of the forceps. In this case they are closed and withdrawn. The brain is then explored by thrusting the forceps first upwards and forwards, then upwards and backwards, and finally upwards and inwards; in the latter case it is unwise to pierce the brain for more than an inch and a quarter for fear of entering the lateral ventricle.

If the brain be explored through the outer wall of the temporo-sphenoidal lobe, the first direction in which this is carried out is directly inwards. If this be not successful, the brain is further explored in a direction forwards, upwards, or backwards, the exploratory instrument at the same time pointing slightly inwards.

If exploration proves negative, it may also be necessary to explore the cerebellum. If, however, the surgeon be still convinced that a temporo-sphenoidal abscess exists, he may next pierce the brain with the bistoury, in case the forceps has failed to enter the abscess cavity, perhaps owing to its walls being very thick. If all efforts fail to find the abscess, the little finger may be inserted into the brain itself to see if the resistant wall of an abscess can be felt. This procedure, however, should be avoided if possible, as by doing so it causes destruction of a certain amount of brain tissue.

If an abscess be opened a varying quantity of pus escapes, usually evil smelling. In the more chronic cases it is thick and greenish; in the acute cases it may contain shreds of necrosed brain tissue or be intermixed with bubbles of gas. Sometimes there is also an escape of turbid cerebro-spinal fluid, which if excessive is suggestive either that the lateral ventricle has been opened inadvertently or that the abscess has already burst into it. In these cases the patient is usually comatose or in the state of muttering delirium at the time of the operation.

After the abscess has been opened, the forceps or bistoury should be retained in position until the pus has drained away. A large tube is then pushed into the abscess cavity along the line of the forceps or bistoury. It is only permissible to withdraw the instrument with which the abscess has been opened after the end of the tube is well within the cavity. The outer end of the tube should be flush with the surface of the wound. To prevent it slipping too far into the brain, it may be anchored to the edge of the skin wound by a silkworm-gut suture. If the abscess be drained through the tegmen tympani, it will be difficult to bring the tube out into the wound without kinking it. For this reason I prefer to incise the brain substance slightly outwards after the abscess cavity has been reached, so that a tube can be inserted obliquely upwards and inwards at a point corresponding to the angle between the tegmen tympani and the squamous portion of the temporal bone. If the exploratory puncture has been made above the tegmen tympani and an abscess discovered, the question arises whether another drainage tube should not also be inserted into the brain through an opening in the roof of the antrum so as to drain the abscess from below. This, however, I do not think necessary.

In addition to the rubber tube, many varieties of drainage tubes have been suggested, such as decalcified chicken bone, as originally used by Macewen, and glass or silver tubes; the object of the latter being to resist the pressure of the brain, which may compress a rubber tube. The rubber tube is the simplest form of drainage, and if sufficiently thick it should be employed. To make more certain of free drainage, some surgeons use two tubes placed side by side. I think, however, one large tube (half an inch in diameter) is better than two small ones.

Irrigation of the abscess cavity is still a matter of opinion. If the abscess be small and circumscribed, the best method is to open it with as little disturbance as possible to the surrounding parts, insert a large drainage tube, and to do nothing further.

If, however, the abscess be large and irregular in shape, so that the drainage is not free, and especially if it be very septic and contains necrosed brain tissue, irrigation is justifiable if gently carried out. The best method is to insert a fine tube along the lumen of the large one and allow some warm saline solution to flow slowly along it into the abscess cavity, the fluid returning along the larger tube. If two tubes have already been inserted into the abscess cavity, the fluid injected through one will escape by the other. Whatever method is employed, care must be taken that there is free exit for the fluid, as otherwise the abscess cavity may become over-distended, and in consequence rupture of a portion of its wall may take place, especially the inner, which perhaps only consists of a thin layer of brain tissue separating the abscess from the lateral ventricle. During the act of irrigation there is a risk of some of the fluid, now loaded with septic particles, escaping between the surface of the brain and the dura mater and thus setting up a secondary meningitis.

=Opening of a cerebellar abscess.= The cerebellum may be explored from two different points, either in front or behind the lateral sinus. The posterior route is adopted if the abscess is superficial in the outer portion of the lateral lobe, usually the result of lateral sinus thrombosis or disease of the posterior mastoid cells. The anterior route is indicated if it is thought that the abscess is deeply placed in the anterior inferior portion of the cerebellum, that is, in those cases in which it is apparently a complication of labyrinthine suppuration, or the result of disease of the inner wall of the antrum and mastoid cavities (Fig. 253).

(a) Behind the lateral sinus. After exposure of the lateral sinus the bone is removed either by means of the gouge and mallet or by bone-forceps, until a considerable area of the dura mater is exposed behind and below the curve of the sinus (Fig. 253). The dura mater is then incised as already described.

The cerebellum is explored by thrusting the instrument inward for about an inch. As a rule the abscess is found at once. If it be not discovered at the first attempt, the instrument should be directed forwards, upwards, and inwards towards the posterior surface of the petrous bone. Care, however, must be taken that it is not pushed in too far, otherwise it may pierce the anterior upper margin of the cerebellum, and if an abscess be present, the meninges may thus become infected. If the surgeon has exposed the dura mater by trephining, it is necessary to push the exploratory instrument at least two inches inwards and forwards in order to reach an abscess situated in the anterior inferior portion of the cerebellum. In such cases it is by no means difficult to miss a small abscess, and further, drainage is frequently incomplete when an abscess is discovered. For this reason, if the cerebellum be explored first behind the lateral sinus and no abscess is discovered, it should further be explored by the anterior route in front of the lateral sinus. If the cerebellar abscess be secondary to lateral sinus thrombosis, and if there be no doubt as to the diagnosis, the inner wall of the sinus should be made as aseptic as possible, and the dura mater forming it incised freely; the cerebellum being thus explored through the site of infection.

(b) In front of the lateral sinus. The lateral sinus is first exposed (Fig. 253). The triangular area of bone situated in front of it, between it and the semicircular canals, and forming the inner boundary of the antrum and mastoid cavities, is now removed with the gouge and mallet or with a suitable pair of forceps. If it be certain that internal-ear suppuration exists, or if the operation be secondary to opening of the labyrinth, the posterior wall of the petrous bone may be removed until the internal auditory meatus is almost reached. If, however, the labyrinth be intact, care must be taken not to chisel away too much bone for fear of encroaching on the posterior semicircular canal. On exposure of the dura mater an extra-dural abscess may be met with, usually the result of internal-ear suppuration. Even if no pus be seen, it is always a wise precaution, if internal-ear suppuration coexists, to separate the dura mater from the posterior wall of the petrous bone by means of an elevator in order to prevent any deeply situated extra-dural abscess being missed. After the dura mater has been exposed sufficiently it is opened by a crucial incision. In this region absence of increased tension within the brain and lack of bulging outwards of the cerebellar tissue do not necessarily imply the absence of an abscess; the cerebellum to all appearances may appear normal and flaccid, although a small abscess may be present.

The cerebellum is explored in various directions to a distance of not more than one inch. After the pus has been evacuated a tube is inserted as described above. In the majority of cases this method is far superior to opening the cerebellum behind the lateral sinus, especially as it is now recognized that the chief cause of cerebellar abscess is internal-ear suppuration.

=After-treatment.= This is similar to that of any ordinary abscess, but care must be taken that free drainage is maintained. The main part of the mastoid wound is lightly plugged with gauze, the tube inserted into the brain abscess being brought flush with the surface of the skin. The gauze filling the wound cavity should be arranged around the tube so that it rests comfortably within the wound and is not kinked. If the drainage tube be in its proper position, pus should be seen to ooze out of it.

Although the mastoid cavity itself need not be dressed daily, if necessary the outer dressings may be removed twice a day, in order to see that drainage of the abscess is continuous. After the first two or three days, the tube is gradually shortened. If the abscess be a recent one and not encapsuled, it becomes rapidly obliterated by pressure of the surrounding brain tissue, so that the tube may be forcibly ejected within a few days. On the other hand, if the abscess has existed for a considerable period and is bounded by a thick wall, which may be extremely resistant, the purulent discharge may continue for many days and necessitate the continuance of drainage. Generally speaking, the tube may be shortened every second or third day, and can usually be dispensed with by the end of the second week, if not before. It is, however, very necessary that the tube should not be withdrawn until it is certain that the abscess cavity has been obliterated completely.

The general treatment of the case in no way differs from that already described for the mastoid operation in which the wound has been left open posteriorly.

=Complications.= (i) On turning back the flaps of the dura mater, a hernia, consisting of friable congested brain tissue, may occur at once. This is extremely rare as a result of a simple abscess of the brain, but is significant of encephalitis frequently associated with meningitis (see p. 436). If an abscess be suspected, the brain should be explored as already described. If, however, no abscess be discovered, the treatment consists in removal of more bone and further incision of the dura mater, in order to permit of free drainage and to relieve tension.

(ii) Opening into the lateral ventricle. This may be due to rupture of its wall owing to the sudden diminution of pressure from too rapid drainage of the abscess cavity, or it may occur accidentally from thrusting in the exploratory instrument or drainage tube too deeply. Its occurrence is evidenced by the sudden gush of cerebro-spinal fluid. The ultimate danger is subsequent infection of the cavity, which, unfortunately, frequently occurs.

(iii) Cessation of breathing. This is more likely to occur in a cerebellar abscess in consequence of direct pressure on the medullary respiratory centres. The immediate treatment is to do artificial respiration and to open the cerebellar abscess by the quickest method possible. If this be successful, respiration probably will be restored.

=Prognosis and subsequent progress.= In an uncomplicated case a favourable prognosis may be expected, provided the abscess is successfully opened and drained without much disturbance of the surrounding parts. Many factors, however, may lead to a fatal result. With regard to recovery: in 100 cases taken from the records of the London Hospital during the last ten years, recovery took place in 20% operated on for cerebral and 10% for cerebellar abscess. Other statistics give a much higher percentage of recovery, but it must be remembered that in hospital patients a large number of the cases are only seen by the surgeon at a very late stage, when the brain abscess is complicated by other intracranial or suppurative lesions, and the patient is in an almost moribund condition; so that the operation may only be undertaken as a forlorn hope.

If the operation is going to be successful, the head symptoms quickly disappear. Even if the patient was comatose before operation, the recovery may be so rapid that his mental condition may be almost normal within twenty-four hours. In many cases, if the abscess be a large one, convalescence will be tedious or prolonged; sometimes, indeed, complete restoration of the mental faculties, in spite of a most successful operation, will not be obtained. The chief relief to the patient is the cessation of the terrible headaches from which he has been suffering.

Unfavourable symptoms are the sudden onset of pyrexia accompanied by delirium usually the result of diffuse meningitis, or of infection of the lateral ventricles. In the latter case there is a rapid termination in drowsiness, coma, and death.

Although the brain abscess may be draining freely, the patient for some days may lie in a semi-comatose condition as a result of œdema or inflammation of the surrounding brain tissue; in such cases prognosis is difficult, but hope of recovery may be entertained if the pulse and temperature keep practically normal.

=Recurrence of symptoms.= This may take place within the first few days after the operation as a result of infective cerebritis, the presence of another abscess, or faulty drainage; or at a much later period, owing to the formation of another abscess or to a cyst within the brain at the site of the former abscess.

1. If the recurrence of the symptoms appears immediately after the operation, the wound should be inspected carefully, if necessary under an anæsthetic. If drainage be not free, the tube should be removed and a pair of forceps inserted along the track leading into the abscess, their blades being then slightly opened and withdrawn. On doing this an accumulation of pus may escape. The cavity may then be irrigated gently with saline solution and a larger tube inserted.

If, however, this procedure does not give a satisfactory result, the finger may be inserted into the brain to feel if the abscess is loculated. By this means any existing septa may be broken through; or if a feeling of resistance suggests the presence of another abscess, this part of the brain can also be explored. It must also be remembered that although a temporo-sphenoidal abscess has been opened successfully and is draining well, the continuance of the symptoms may be due to a coexisting abscess of the cerebellum, or vice versa; in other cases, in spite of all care, the patient gradually sinks, partly from exhaustion and partly from general toxæmia, the result of infective cerebritis.

2. Recurrence of symptoms at a later period. The occurrence of a fresh abscess is usually owing to the fact that the primary focus of the disease has not been completely removed at the first operation; for instance, if the surgeon only trephined and drained the abscess without performing the mastoid operation.

A cyst is usually the result of the abscess having been encapsulated and its wall not having been removed at the first operation. If a cyst be discovered on exploring the brain in consequence of these symptoms, its wall should be removed if possible.

Apart from symptoms of intracranial pressure, the patient may suffer from attacks of Jacksonian epilepsy from time to time, presumably due to the post-operative adhesions. If they continue in spite of conservative treatment, it may become necessary to operate in order to remove this source of irritation (see Vol. III).

SECTION IV

OPERATIONS UPON THE LARYNX AND TRACHEA

BY

W. DOUGLAS HARMER, M.C. (Cantab.), F.R.C.S. (Eng.)

Surgeon to the Throat and Nose Department, St. Bartholomew’s Hospital

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I. ENDOLARYNGEAL OPERATIONS

=Indications.= (i) Tumours. Tumours of the larynx are more often innocent than malignant. Sir F. Semon[5] collected 12,297 cases seen between 1862 and 1888 by 107 laryngologists, and of these 10,747 (or 88%) were benign and 1,550 (or 12%) were malignant. Of the innocent forms, papilloma, either simple or multiple, occurred in 39%; fibroma, sessile or pedunculated, was next in frequency; cystic tumours were not nearly so common; and other forms, including myxoma, angeioma, adenoma, lipoma, and enchondroma, were rare. The period during which these tumours are most common is between the ages of 20 and 40 years, but they are also frequent during childhood.

[5] Internat. Centralblatt für Laryngol., Jahrgang v u. vi, 1888-9, ‘Die Frage des Ueberganges gutartiger Kehlkopfgeschwülste in bösartige, speciell nach intralaryngealen Operationen.’

Malignant growths occur at a later age, mostly between the ages of 40 and 60, and attack males more than females. Carcinoma is far more common than sarcoma, and is generally of the squamous-celled variety. Endothelioma has not often been discovered.

The importance of distinguishing innocent from malignant tumours is greater now than in former years, since it is agreed that endolaryngeal operations are preferable for the eradication of the former, while the latter are better treated by extra-laryngeal methods. Moreover, the differential diagnosis has steadily improved, owing to the more general use of the laryngoscope and the introduction of recent methods of examination. Thus, by direct laryngoscopy it is possible to investigate children as easily as adults. Microscopical examination of fragments removed with laryngeal forceps is of great value in confirming the clinical diagnosis; the sections can be made by freezing, or in paraffin, the latter method requiring, with recent improvements, not more than twenty-four hours. Semon, who has done more than any other man to improve the early diagnosis of malignant disease of the larynx, is strongly in favour of such examinations. It must be remembered, however, that the result is sometimes inconclusive, for it is difficult to be certain that the actual growth has been removed. In cases that are thought to be malignant, it is better to open the thyreoid[6] cartilage than to rely upon endolaryngeal operation, as there is a danger of stimulating the growth to greater activity, especially by repeated interference. When the thyreoid cartilage has been opened, the whole disease can be explored thoroughly and a fragment selected from which to make a frozen section. In the majority of cases a definite diagnosis can thus be arrived at, and even when it is necessary to examine several fragments the amount of time lost is small.

[6] [The spelling of this word has been adopted in conformity with the Basle Anatomical Nomenclature.--Ed.]

As regards the value of skiagraphy, Walsham and myself have found that photographs can be made of tumours of the larynx which in some instances determine accurately the position and extent of the disease.

Fig. 254 is a photograph showing a cancer of the upper opening of the larynx, lying above the vocal cords, the position of which was proved to be accurate by later operation upon the patient. It is, however, doubtful whether the method will eventually assist in the differential diagnosis between innocent and malignant growths.

(ii) Tuberculosis. Endolaryngeal operations are successfully performed for chronic conditions such as ulceration or tumour, and, rarely, in acute forms such as abscess, necrosis, and the like. Removal of a portion of the epiglottis occasionally gives great relief to a patient who is suffering from dysphagia.

(iii) Strictures resulting from trauma, from the ulcerations of syphilis, diphtheria, and other inflammatory diseases, or caused by congenital webs.

(iv) Foreign bodies impacted in the larynx.

(v) Œdema of the mucous membrane due to trauma or inflammation, local abscess, necrosis, and other allied conditions, in which obstruction is likely to supervene.

The operation may be performed either by indirect or by direct laryngoscopy.

OPERATION BY INDIRECT LARYNGOSCOPY

It being essential that the patient should be tolerant, this method is chiefly applicable in the case of adults. The operation may require a course of instruction, but this presents no difficulty if given with discretion. The employment of cocaine, novocaine, and adrenalin is of the greatest importance to both surgeon and patient. Cocaine, which is generally to be preferred, may be used in strong solutions--10 or even 20%--if applied to the mucosa by a small swab of wool; but, if used as a spray, weaker solutions are employed (4%). With neurotic patients cocaine must be applied cautiously, as a sense of suffocation is sometimes produced. It is necessary first to treat the soft palate, the uvula, base of the tongue, pharynx, and epiglottis; secondly, with the help of a laryngeal mirror, the interior of the larynx must be cocainized; this can be accomplished by expelling a few drops of the solution from a laryngeal syringe or by means of a swab attached to a suitable wool-carrier. Fifteen to twenty minutes must be allowed to gain the full effect of anæsthesia. The patient must be instructed on no account to swallow the saliva. The secret of successful intralaryngeal operations lies in the thorough application of these principles, and in not attempting the operation until the patient is able to tolerate the presence of an instrument within the larynx. The surgeon must be experienced in the use of laryngeal instruments, and must be provided with a complete equipment, including forceps (Mackenzie’s, Whistler’s, Grant’s, &c.), which must be of different lengths to suit the patient, snares, galvano-cautery, curettes, probes, and other instruments for the application of drugs. Proper illumination is also very important.

When removing an intralaryngeal growth, the surgeon sits facing the patient. The mouth is opened to the fullest extent, and the tongue drawn well forward and held by the patient’s right hand. The mirror is introduced in such a way that the tumour is distinctly seen. If the epiglottis overhangs, it can be drawn forward with the forceps; or, in rare instances, a special instrument (Fig. 255) can be used for transfixing its upper margin with a thread, the latter being grasped by a pair of pressure forceps, which, being allowed to hang, will automatically raise the obstruction.

The forceps, having been warmed, are taken in the right hand when the tumour is on the right side of the larynx and in the left hand when the tumour is on the left, thus allowing a clearer view than when the same hand is employed irrespective of the position of the disease. It is introduced as follows: firstly, the handle is directed towards the patient’s left ear until the point of the forceps has passed beyond the back of the tongue and lies behind the epiglottis; secondly, the instrument is quickly rotated so that the handle lies below the chin; thirdly, the hand is raised so that the point is directed forwards; fourthly, the whole instrument is quietly lowered and the beak of the forceps directed towards the growth. This manipulation is made more difficult by the laryngeal image being reversed in an antero-posterior direction.

When the point is seen to rest upon the growth, the instrument is opened, and the tumour grasped and avulsed: with careful manipulation there is little danger of wounding the normal mucosa, and hæmorrhage is insignificant. When dealing with multiple growths the patient must understand that it may be necessary to repeat the operation, either immediately or after an interval. Given suitable instruments, sufficient experience, and a tolerant patient, it is possible to remove, with the help of cocaine, the majority of simple tumours. Operations upon cysts, the scarification of mucous membrane with a guarded knife, the curettement of tuberculous ulcers, and cauterization of the larynx, are all conducted upon similar lines. Foreign bodies can generally be removed with forceps; thus, F. A. Rose[7] reported a case in which part of the breastbone of a chicken, measuring 1 inch in length and over 3/4 of an inch in width, was removed after having been impacted in the larynx for nearly forty-eight hours. In rare instances such an operation is not successful; e.g. with a foreign body firmly impacted, multiple papillomata, or an intolerant patient, general anæsthesia may be required, and removal may have to be effected through a tube-spatula or by external incision.

[7] Proc. Roy. Soc. Med. London, vol. i, No. 2, Laryn. Sect., p. 5.

=After-treatment.= Intralaryngeal wounds generally heal well, but every effort should be made to prevent infection of the parts, to allay any inflammation that may arise, and to avoid catarrh and swelling of the mucosa. It is advisable to order complete vocal rest until the redness has subsided, and the patient should refrain from coughing; the sucking of ice, or the inhalation of benzoin or other medicated steam, has a sedative action upon the parts. If the larynx becomes septic or filled with irritating discharge, the use of sprays or powders is indicated; in such a case the patient may be given a parolein spray, with menthol, eucalyptus, or other antiseptic, for constant use; or a powder such as orthoform, the latter being sucked into the larynx through a warmed glass tube (Leduc’s insufflator), or applied by the surgeon. In the later stages the patient may be treated by the local application of caustic fluids, or by galvano-cautery, as occasion requires. The success of such operations depends largely upon the skill of the surgeon; if attention be given to the after-treatment the results are very good, and the voice is generally recovered. As Semon has shown conclusively, there is no practical danger of the occurrence of malignant degeneration through the influence of instrumentation.

OPERATION BY DIRECT LARYNGOSCOPY

=(Killian’s Method)=

=Indications.= (i) Multiple papillomata. These tumours occur most commonly during the early years of life, and operations for their removal present great difficulties, first, in their removal, and, secondly, owing to their inveterate tendency to recurrence whatever operation is performed; moreover, in some instances operation seems to stimulate the growths to greater activity. The case reported by Stoker is a well-known instance. He was consulted by a man thirty years of age who had suffered from papilloma for twenty-three years, during which period one surgeon had performed 100, and a second 120 operations.

(ii) Benign tumours other than papillomata, which are not amenable to operation by indirect laryngoscopy.

(iii) Foreign bodies. Direct laryngoscopy is advised for patients who are intolerant (e.g. young children), or when the object is firmly impacted, or when other methods of treatment have failed. Thus in one of my cases a man presented himself with a long pin impacted transversely above the vocal cords; it was found impossible to remove it by indirect laryngoscopy without serious injury to the parts. An anæsthetic was therefore given and a large tube-spatula passed into the larynx: with strong forceps the pin was bent upwards and removed with ease.

(iv) Granulations, ulcers, necrosis, and other inflammatory conditions such as are caused by diphtheria, tubercle, syphilis, and many other diseases.

(v) For diagnostic purposes. There can be little doubt that direct laryngoscopy has a great future before it as a means of determining the nature of doubtful laryngeal conditions. If the upper parts of the larynx be swollen, if there be any stenosis such as follows ulceration, or if the patient be intolerant, the air-passages cannot be thoroughly examined with the laryngoscope alone. With the newer method many of these difficulties have disappeared, and it is now possible for the surgeon to diagnose with certainty many conditions which would otherwise have remained doubtful.

The apparatus required consists of:

(a) The tube-spatulæ. The tube originally suggested by Killian was made of straight metal and circular in section, the distal end being cut obliquely with the projecting portion fashioned like a spatula. A strong handle, at right angles to the tube, was used for manipulation. Different sizes were required for children and adults. Various modifications of these tubes are now in use, notably those of Mosher and Bruenings: the instrument recommended by the latter is easier to manipulate and gives a better view than the earlier forms described.

(b) The lamp for illumination. Different forms of head-lamp (Killian’s, Kirstein’s) and hand-lamp (Caspar’s) have been devised for illumination from the outside, and Chevalier Jackson has invented a lamp which is sufficiently small to pass to the distal end of the tube, where it lies in a compartment of its own lest it should be broken and fall into the trachea. Recently these electroscopes have been improved upon by Bruenings, in whose instrument (Fig. 257) the lamp is more powerful and is attached to the handle in such a manner that it can be easily swung into position when required. A condensing lens has also been added and the light can be focused to any desired distance. If preferred, an ordinary forehead-mirror reflecting the light from a powerful Nernst lamp (100 c.p.) can be employed.

(c) The instruments for operation. Various forms of forceps for removal of tumours have been devised by Killian, von Eicken, Bruenings, Patterson, and others. In any form that is employed it is necessary, in order to allow of clear vision, that the handle should be set at an angle with the shaft. For foreign bodies, hooks of different shapes are also useful. Other requirements include a gag for opening the mouth, a tongue depressor, tongue forceps, suitable cotton-wool carriers, the requisites for tracheotomy, and a darkened room.

=Operation.= The operation can be performed with local or general anæsthesia. With patients who are intolerant chloroform is more reliable, and is preferable to other drugs, which tend to excite secretion. Chloroform should always be employed for children. It should be given slowly and in the smallest possible quantity, the head of the patient being kept lower than the body to allow blood and mucus to drain away from the trachea. To make the parts more tolerant, cocaine can also be applied to the vocal cords, or a dose of morphine (codeine is advised in children) can be given half an hour before the operation. The importance of a skilled anæsthetist cannot be too strongly emphasized. With chloroform, the patient should lie upon the back or right side, with the head projecting beyond the end of the table, so that the neck can be extended as required. With cocaine the upright position is often preferred, and the patient should sit on a low stool facing the surgeon. When the patient is recumbent, the surgeon should sit or kneel behind the head (Fig. 258). He should observe the strictest antiseptic precautions, and should introduce no instrument which has not been properly sterilized; further, the tubes should be previously warmed to prevent ‘fogging’, and oiled with sterilized liquid paraffin before introduction. There should be two assistants, one (the chloroformist) to support the head and watch the respiration and pulse, the other to help with instruments.

In order to examine the larynx, the mouth is opened by a gag, and the tube-spatula is passed to the upper border of the epiglottis; when this has been inspected the spatula is pushed behind it, and the upper portion of the cricoid plate is examined; the tongue is then pulled forward and the tube tilted so that the larynx can be seen. The examination should be methodical, and should include the vocal cords, ventricular bands, and openings of the ventricles. The whole manipulation can be performed with great delicacy, and is entirely guided by the eye, so that there is little fear of injury even in young children.

In this and the further technique the chief difficulties are caused by: (a) The prominence of the upper teeth. This may seriously interfere with the easy passage of a straight tube, even when the neck is fully extended. The difficulty can be overcome by turning the head laterally, so that the tube passes through the opposite angle of the mouth. (b) The mucus, which collects in the tube and obstructs the vision. This must be overcome by using a secretion aspirator, by frequent sponging, or, as suggested by Ingals, by giving a previous dose of atropin[e]. (c) Intolerance of the parts, which can be counteracted by the judicious use of cocaine (10%). It may be noted that this combination of chloroform and cocaine is not dangerous, even in young children, so long as the cocaine is prevented from running into the pharynx.

The condition of the larynx having been thoroughly examined, the operation can proceed. The method of removing multiple papillomata will first be described. In some cases it will be found that better exposure of the tumours is obtained if the end of the tube is placed above the epiglottis rather than in the larynx itself. The position of the growths having been determined, a suitable forceps is selected and introduced through the tube. The papillomata are seized and avulsed separately, without injury to the normal tissues. To arrest the bleeding it may be necessary to apply cocaine and adrenalin mixture, and to raise the foot of the table so that the blood drains away from the field of operation. As far as possible, all the growths should be removed; it may be difficult to attack those which are situated in the anterior commissure or subglottic region, but this difficulty may be overcome by the use of specially devised instruments; thus, von Eicken has invented a tube which is long enough to pass through the larynx and into the trachea, the portion lying in the larynx being provided with a lateral window which can be turned in any direction, so that a growth can be made to project into the tube, where it can be easily removed.

At any moment during this operation the surgeon may be called upon to perform tracheotomy.

=After-treatment.= This must be carried out upon the same lines as those already suggested; everything must be done to relieve congestion and irritation. Killian advises internal administration of arsenic for a period of several months, and, if this fails, potassium iodide in large doses. It should be remembered that in some instances syphilis seems to play an important part in the causation of these conditions. Ingersole suggests that X-rays prevent recurrence, and may even cause shrinkage of existing growths.

Recurrence occurs in most cases in some degree, and requires further operation; this may be carried out after an interval of a week or longer, according to the case. At these secondary operations it may not be necessary to use the forceps; local applications such as absolute alcohol, salicylic acid in absolute alcohol (2-10%), solutions of silver nitrate or chromic acid, and many other drugs, have been advised by different surgeons. Wylie is strongly in favour of the galvano-cautery, and is of opinion that the technique is more reliable and the liability of local infectivity diminished. If the latter method be employed, very little should be done at one sitting, otherwise great inflammatory reaction may be set up, entailing tracheotomy. A tracheotomy tube may be required for a short time while such treatment is being carried out; some surgeons, with whom the author does not agree, always perform preliminary tracheotomy, and claim that the papillomata are less likely to recur if complete rest is thus given to the larynx.

=Results.= In discussing the value of the above method it is necessary to refer to the results obtained by other operations, such as--

(i) Tracheotomy (see p. 522). This operation has been advocated as a method of curing papillomata. It has been noted that by giving rest to the larynx the congestion is relieved, the papillomata decrease in size, and in some cases completely disappear. Mackenzie[8] published seven cases which he had had under observation for a minimum of two years, with four recoveries, the canula having been worn for periods varying from six to fifteen months. He also mentioned thirteen other cases in which good results had been obtained by other surgeons, and was of opinion that the method was most successful with ‘virgin’ cases. There are, however, many objections to this form of treatment. For instance, it is often necessary to retain the tube for a prolonged period, two years or longer, and even then the result is doubtful; moreover, the prolonged use of a canula is disastrous to the larynx, not only in retarding development, but also in the production of stenosis; there is also a danger of bronchitis, of broncho-pneumonia, and possibly of tuberculosis. In regard to the last, G. A. Wright,[9] in reporting a case in which tubercle supervened, argues that ‘presumably there is more risk of this happening to the wearer of a tracheotomy tube than when breathing in a normal way through the mouth or nose’. Further, the line of treatment is difficult to enforce on account of the aversion shared by most parents to the performance of tracheotomy.

[8] Brit. Med. Journ., 1901, vol. ii, p. 883.

[9] Ashby and Wright, Dis. of Child., 4th ed., p. 350.

(ii) Laryngo-fissure (see p. 487). Under this head are included thyrotomy, or complete division of the thyreoid cartilage; partial thyrotomy, where a small portion of the upper or lower part of the thyreoid cartilage is left intact (an operation which does not give a good exposure of the larynx); infrathyreoid laryngotomy, which is only applicable to adults; cricotomy, with division of the cricoid cartilage and crico-thyreoid membrane; and subhyoid pharyngotomy. Of the above, thyrotomy is the most satisfactory operation, because it gives the best exposure of the parts and facilitates removal of the growths; recurrence, however, is frequent, permanent injury to the voice is common, and stenosis may result.

The results of these operations, especially during childhood, are by no means satisfactory. In the statistics carried up to 1896, collected by Rosenberg and von Bruns,[10] laryngotomy was performed 143 times on 109 children; 11 were operated upon twice, 3 children three times, and 1 child seventeen times. 52 of the children were under four years of age; 20 died, principally from suffocation with recurrent papillomata; 43 showed recurrences after repeated operation; 40 were cured (i.e. 36%), and of these 10 showed disturbance of voice.

[10] Bergmann, E. von, Sys. Pract. Surg., vol. ii, p. 231.

It must be admitted that operations for the treatment of papillomata do not meet with any great measure of success. It seems probable, however, that the results obtained by endolaryngeal removal are better than those obtained by either tracheotomy or laryngo-fissure. To quote Killian[11]: ‘Formerly, and especially from the standpoint of the surgeon, laryngotomy for laryngeal papillomata was very frequently done in little children in whom removal was impossible by endolaryngeal methods. In my judgment, direct laryngoscopy renders such a surgical procedure unnecessary. We can in all cases, with the aid of a tube-spatula under narcosis, remove papillomata, and the operation can be repeated as often as seems necessary.’ These remarks express the general feeling of the present day, and the most important factor in determining the success of operative treatment is early diagnosis. Such diagnosis divides the cases into two classes: those in which the growths are localized, and those in which they are diffuse. The first class is easy to treat by endolaryngeal methods, and, given careful after-treatment, the prognosis is satisfactory. The second class is serious, and far more difficult to treat; when Killian’s method fails the prognosis is very bad. Finally, it must be borne in mind that, as recurrence may not occur for several months, a guarded prognosis must be given in every case.

[11] Trans. Amer. Laryng. Assoc., 1907, p. 127. Discussion of paper by C. G. Coakley on ‘Removal of papillomata of larynx by direct instrumentation with the aid of Killian’s tubes.’

The removal of other benign tumours and of foreign bodies, and the treatment of granulations, are conducted upon similar lines, and are attended with excellent results.

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