Diseases of the ear

Front matter

Class ^SHZ^i/—

Book M ^ (o. .

CoptghtN°_-._ I^Xi

Preface To Second Edition

While the past few years have been marked by no startling developments in otology, advances of a practical order have not been wholly wanting. Our conception of the pathology, processes of repair and rationale of treatment of certain lesions has undergone very considerable modification. The mastoid operation of a few years ago was a bone operation pure and simple. To-day the plastic work vies in practical importance with that upon the temporal bone itself. In other words, our conception of the important role which the soft parts may play in post-operative tissue repair has led logically to a different surgical technic, which, in turn, has given us better and quicker results. To record these developments parts of this chapter have been practically rewritten. Again, the further study of the changes in the cerebrospinal fluid occurring in various diseases has conduced materially to a more correct interpretation of the meningeal lesions and disorders of otitic origin and has brought to light certain sources of error in diagnosis. Beyond such changes and additions as were necessary to bring these practical phases of otology in line with modern ideas, alterations in the text and arrangement of the subject matter have been avoided.

Two new chapters have been added, of which the first is devoted to Barany's theory of the cerebellar control of joint movements, with a discussion of the pointing tests in their relation to vestibular and cerebellar disea'se. The second includes a brief account of the various tj'-pes of war deafness, — deafness due to direct injury of the skull, nerve deafness due to loud explosive noises, concussion deafness due to the air displacements of near-by explosions, psychic disturbances of function, pithiatism, etc.,— phenomena which constitute for most of us a practically new chapter in aural disease. Direct products of military hardship and injuries, as these lesions and functional disorders undoubtedly are, their relation to certain phases of some of the commoner ear lesions is sure to provide a fruitful field for futiu-e investigation and discussion. It is hoped, therefore, that the changes and additions which distinguish this edition from the first may prove to be ot distinct practical usefulness to students and practitioners of otology

Peilip D. Kerrison.

Ill

Preface

Probably in no branch of medicine have more notable advances been achieved during the past decade than in otology. The wholly new field of work which has been opened to us by the successful investigation of the static labyrinth ; the new light upon syphilitic lesions of the labyrinth and auditory nerve resulting from the recent world-wide renewal of interest in the study of all phases of syphilis; and the investigations still in progress as to the influence of autogenous vaccines and leucocyte extracts upon certain phases of aural disease, — these and other additions to our knowledge have suggested new problems in the working out of which laboratory investigations have been closely followed by practical therapeutic results.

In aural surgery our activities can no longer be confined to the narrow limits of the tympanum and mastoid process, but must include the more hazardous field of intracranial surgery and the yet more delicate and difficult work upon the auditory labyrinth itself. There is, then, some justification at the present time for yet another book, — i.e., an attempt to^ present the complex subject of otology in the light of recent advances.

If the arrangement of the subject matter, particularly as to the proportionate space given to the different subjects, represents a departure from that usually followed, this has become necessary in order to bring the various subjects now pertaining to otology into a true relation with their actual and proportionate importance.

For example, labyrinthine physiology, suppurative diseases of the labyrinth, and the surgery of the labyrinth, which are usually rather briefly dealt with, are here considered in three separate chapters which occupy a very considerable section of the book. Again, the suppurative lesions of the brain and meninges are accorded far more space than is usually allotted them in text-books of otology.

In the Section devoted to operative surgery, the plan of illustrating each successive step of the various operations has been adopted. This, it is believed, will be of special value to students of otology living at a distance from the larger medical centres and who are therefore denied the educational advantages of large surgical clinics. "With few exceptions, the illustrations throughout the book are from original drawings made under the writer's personal supervision.

vi PEEFACE

In the preparation of this manual the writer has endeavored to give greatest prominence to the practical side of otology. This has necessitated the elimination of many time-honored but discarded theories and therapeutic measures which no longer have any bearing upon the practice of otology.

In conclusion, I wish to express my thanks to Dr. J, H. Guntzer for many valuable abstracts from the literature, and to Miss Eleanor Fry, whose clever and anatomically correct drawings form so attractive and valuable a feature of this book. I wish also to express my indebtedness to the publishers, Messrs. J. B. Lippincott Company, for many helpful suggestions as to the arrangement of the text.

Philip D. Kerrison.

Chapter I Pagb

Anatomy and Physiology of the Sound Conducting Apparatus 1

The Auricle 1

Muscles of the Auricle 2

The External Auditory Meatus 3

Development of the Osseous Meatus 4

Post-natal Changes 7

The Osseous Meatus 8

The Tympanum 9

The Inner Wall 11

The Superior Wall 12

The Anterior Wall 13

The Posterior Wall 14

The Inferior Wall 14

The External Wall 15

The Annulus Tymp.anicus 16

The Drum Membrane . 16

The Ossicles 16

The Malleus 16

The Incus 18

The Stapes 18

iShrapnell's Membrane 20

The Ossicles, Their Articulations and Relative Positions Within the

Tympanum 20

The Malleus 21

Ligaments of the Malleus : 21

The Incus 22

Articulations-oe THE Malleus and Incus 22

The Incudo-stapedial Joint 23

Articulation of the Stapes with the Fenestra Ovalis 23

The Intra-tympanic Muscles 23

The Stapedius 23

The Tensor Tympani Muscle 24

The Lining Membrane of the Tympanum 2*4

The Pouches, or Pockets, of the Membrana Tympani 24

The Attic Spaces 26

Vascular and Nervous Supply of the Tympanum 26

Arteries • 26

Veins 27

Nerves 27

The Eustachian Canal 28

The Osseous Portion of the Eustachian Tube 28

The Membrano-cartilaginous Portion of the Eustachian- Tube .... 29 Anatomical Differences Between the Eustachian Tubes of the

Adult and the Infant at Term 30

Muscles op the Eustachian Tube 31

The Mastoid Process '. 31

The Pneumatic 32

The Diploic Mastoid 32

The Antrum 32

Physiology of Sound-conduction 34

The Pitch 34

Intensity 35

Timbre 35

vii viii CONTENTS

Sound-conduction 35

Auricle and External Auditory Meatus 35

The Drum Membrane 36

The Ossicular Chain '. 37

The Tympanic Muscles 39

CHAPTER II Physical Examination of the Patient 41

Age, Occupation, Habit, Heredity 41

Previous History 41

History of the Present Attack 41

Objective Examination 42

Auricular Displacement 43

Palpation in Case of Postauricular (Edema - 43

Palpation of the Auricle in Case of Aural Pain 44

Inspection of the Drum Membrane 44

The Source of Light 49

Technic of Objective Examination; Landmarks of the Normal

Drum Membrane 50

Landmarks of the Normal Drum Membrane 53

Examination of the Eustachian Tubes , 60

Valsalva's Method of Inflation 60

Politzer's Method of Inflation 61

Inflation Per Catheter 63

The Nose, Nasopharynx, and Throat 69

Examination of the Nose 70

The Throat . 70

Posterior Rhinoscopy 71

CHAPTER III Functional Examination of the Cochlear x^pparatus; Hearing Tests 73

Air Conduction and Bone Conduction of Sound 73

Normal Hearing Distances for the Watch-tick, the Acoumeter, the

Conversational Voice and Whisper 74

The Watch-tick 74

Politzer's Acoumeter 74

The Conversational Voice and Whisper 75

Recapitulation 76

Changes in the Tone Limits 76

Loss OR Impairment of Hearing for the Lower Musical Tones. .... 76 Loss OR Impairment of Hearing for the Higher Tones of the Musical Scale 77

Changes in the Period of Hearing by Bone Conduction 77

Increase 77

Diminished Hearing by Bone Conduction 79

Method of Examination 80

Watch and Acoumeter 80

Whispered and Conversational Speech 81

Determination of the Lower Tone Limit 83

Determination of the Upper Tone Limit 86

Changes in Hearing by Bone Conduction 87

Total Deafness 91

CHAPTER IV Diseases of the External Ear (Auricle; External Auditory Meatus) 97

Inflammatory Diseases of the Auricle 97

Traumatic Auricular Dermatitis 97

Erysipelas of Auricle 97

CONTEXTS ix

Frost-bite 98

Auricular Eczema 98

Symptoms of Acute Auricular Eczema 99

Chronic Eczema of the Auricle 100

Auricular Perichondritis 101

Terminations 101

Hematoma Auris (Othematoma) , 102

Terminations ., 103

Lupus 104

Lupus Tumidus (Lupus Hypertrophicus) 105

Syphilis of the Ear 105

Herpes Zoster Auricula; Herpetic Inflammation of the Geniculate Ganglion (Hunt) 106

Malignant Disease of the Auricle; Epithelioma; Cancer of the

Auricle 107

Inflammatory Diseases of the External Auditory Meatus 107

Acute Circumscribed External Otitis 107

ETiOLoeY 107

Physical Examination 108

Courses of the Disease 109

Prognosis Ill

Treatment Ill

Acute Diffuse External Otitis 116

Causes 116

Otomycosis 117

Croupous External Otitis (Otitis Externa Crouposa) 118

Obstructive Conditions of the External Auditory Meatus 119

Foreign Bodies in the Meatus 119

Removal of a Foreign Body by Means of the Syringe 119

Cases Requiring the Use of Instruments 120

Removal of Cerumen from the Meatus 123

Exostoses OF THE Osseous Meatus; Bony Outgrowths from the

Walls of the Bony Canal 125

CHAPTER V Predisposing Causes 126

Age 126

Nasal Obstruction 126

Exciting Causes 127

Acute Rhinitis 127

X CONTENTS

Acute Infectious Diseases • 127

External Causes 129

Occupations and Habits as Causes of Aural Disease 130

CHAPTER VI The Subjective Symptoms op Aural Disease 133

Aural Pain 133

Pain in Acute Otitis Media 133

Pain in Chronic Catarrhal Otitis Media 133

Pain in Furunculosis of the Meatus 134

Reflex Aural Pain 134

Impairment of Hearing 134

Aural Discharge 135

Discharge in Acute Otitis Media 135

Discharge in Chronic Suppurative Otitis 135

Tinnitus Aurium 136

Obstruction Sounds 136

Blood Sounds 138

Labyrinthine Sounds 140

Neurotic Sounds 141

Cerebral Sounds 143

CHAPTER VII Acute Inflammatory Diseases of the Eustachian Tube, Middle Ear, and

Mastoid Process 145

Acute Tubal Catarrh; Eustachian Catarrh; Tubotympanic Congestion 145

Tubal Catarrh 145

Physical Signs 147

The Course of the Disease 148

Tubal Catarrh in Children 153

Absence of Subjective Symptoms 155

Physical Examination 155

Myringitis 156

Acute Middle-ear Inflammation 157

Nomenclature: Significance of Names in Common Use 157

Otitis Media Catarrhalis Acuta; Acute Catarrhal Otitis Media.. . 158

Anatomical Conditions in Relation to Symptoms 160

Symptoms and Signs 160

Acute Suppurative Otitis Media; Acute Purulent Otitis Media

(Otitis Media Purulenta Acuta) 165

Anatomical Conditions Influencing the Pathology of the

Disease 165

Symptoms and Signs 166

Complications of Acute Purulent Otitis Media 170

Acute Mastoiditis 181

CONTENTS xi

CHAPTER VIII Chronic Middle-ear Suppuration 192

Otitis Media Purulenta Chronica 192

Symptoms and Signs ' 198

Complications 205

Chapter IX

Chronic Non-suppurative Diseases of the Middle Ear; Otosclerosis. ..... 219

Chronic Tubal Catarrh 219

Nasal Obstruction 221

Chronic Tubal Congestion 221

Structural Narrowing of the Tube 222

Chronic Non-suppurative Tympanic Disease 223

Chronic Hypertrophic Otitis Media 223

Physical Signs 226

Chronic Hyperplastic Qtitis Media 234

Physical Appearances of the Drum Membrane 236

Course of the Disease; Prognosis 238

Symptoms and Diagnosis 250

Otosclerosis with Involvement of the Cochlea 253

-Otosclerosis Complicated by Chronic Catarrhal Otitis Media .... 255 Treatment 255

CHAPTER X The Anatomy and Physiology of the Labyrinth 260

The Osseous Labyrinth 260

The Membranous Labyrinth 265

Physiology of Sound Perception (Cochlear Function) 274

CHAPTER XI Inflammatory and Suppurative Lesions of the Labyrinth 278

Ewald's Experiments 278

Barany's Experiments; The Caloric Reactions 280

Vestibular Nystagmus 281

Physiological Nystagmus 283

Rotation or Turning Experiment 283

The Symptom Complex of Vestibular Irritation: Nystagmus, Vertigo, Ataxia 287

Suppurative Labyrinthitis 292

Diffuse Suppurative Labyrinthitis 292

Terminations ; Prognosis 309

Circumscribed Suppurative Labyrinthitis 309 xii CONTENTS

Diffuse SERors Labyrinthitis 310

Perilabyrinthitis 312

A.CUTE Hyperemia of the labyrinth 313

Prognosis and Treatment of Diffuse Suppurative Labyrinthitis. . 313

Treatment of Circumscribed Suppurative Labyrinthitis 318

Treatment of Diffuse Serous Labyrinthitis 320

Treatment of Perilabyrinthitis 320

CHAPTER XII Symptoms of Intracranial Disease Secondary to Aural Suppuration 322

Headache 322

Vomiting 323

Temperature Changes 324

Changes in Pulse Rate 325

Unilateral Muscular Spasm as a Symptom of Cerebral Disease 326

Unilateral Muscular Paralysis or Paresis 327

Mental Disturbances 330

Aphasia 331

Sensory Aphasia 334

Motor Aphasia 336

Motor Agraphia 336

Chapter XIII

Intracranial Lesions of Otitic Origin: Extradural Abscess; Perisinous Abscess; Septic Sinus Thrombosis or Phlebitis; Purulent Leptomeningitis; Cerebral Abscess; Cerebellar Abscess. 337

Avenues of Infection 337

Extradural Abscess; Epidural xA.bscess 338

Perisinous Abscess and Infective Sinus Phlebitis 340

Perisinous Abscess 340

Infective Sinus Phlebitis; Suppurative Thrombophlebitis of the

Sigmoid or Lateral Sinus; Sigmoid Sinus Thrombosis 343

Abscess of the Brain 357

Cerebellar Abscess 375

Differential Diagnosis. 379

Otitic Meningitis 382

Circumscribed Pachymeningitis 382

Leptomeningitis 382

Diffuse Purulent Leptomeningitis 383

Paths of Infection 383

Circumscribed Leptomeningitis 385

Serous Meningitis; Serous Meningoencephalitis (Korner) 387

Meningismus •■ 389

Differential Diagnosis 389

CONTENTS xiii

Chapter XIV

Barany's Theory of Cerebellar Centres: Normal Accuracy in Pointing WITH Eyes Closed; Normal Reaction Movements in Response to Vestibular Irritation; Loss of Pointing Accuracy And Changes in Reactions TO Vestibular Irritation in Cerebellar Disease 394

Cerebellar Centres, Function of 394

Effect — Disease or Destruction of 394

Location of 395

Evidences of Correct Localization 395

Normal Pointing Accuracy 395

Method of Determining 395

Pointing Reactions in Response to Vestibular Disease 395

Method of Applying Tests 395

Changes in Pointing Accuracy in Cerebellar Disease 396

Chapter XV

Surgical Operations for the Relief of Suppurative Lesions of the Middle Ear and Mastoid Process; Myringotomy; Mastoidectomy; The Radical Operation; Ossiculectomy 399

Myringotomy; Incision of the Drum Membrane Paracentesis 399

Operative Dangers 400

Preparation for Operation 402

Anesthesia 403

Technic 403

Possible Repetitions 406

Surgical Landmarks of the Mastoid Cortex 406

Mastoidectomy; The Mastoid Operation; Sometimes Called "Schwartze's

Operation " 409

Preparation of the Patient 409

Instruments 412

Position of patient on Table 412

The Initial Incision 413

The Bone Operation 414

RationalThoroughness in Obliterating the Mastoid Cells .... 422

The Element of Time in Mastoid Surgery 425

The "Blood-clot Operation" (Blake, Reik) 430

Surgical Treatment of Chronic Middle-ear Suppuration 432

Radical Mastoid Operation; Schwarzte-Stacke Operation 432

Preparation of the Patient 433

The Incision 433

Zanfal-Heine Operation 443

Stacke's Operation 444

The Korner Flap 449

The Panse Operation 450

The Siebenmann Flap 450

The Influence of the Radical Operation upon Hearing 455

The Heath Operation for Chronic Middle-ear Suppuration . . . 455

Bondy's Operation 456

Streit's Operation 457

Ossiculectomy 457

Preparation 457

The Instruments 458

Operation 458

Plastic Operations for Closinc? a Postaitricitlar Opening Foll*ow-

iNG the Radical Operation 450

Mosetig-Moorhof Operation 459

The Passait-Trautmann Operation 460

Author's Operation for Preventing or Closing Postauricular

Fistula Following the Radical Operation 461 xiv CONTENTS

CHAPTER XVI Labyrinthectomy; the Radical Labyrinth Operation; Surgical Drainage of

THE Labyrinth 463

Indications 463

Surgical Guides to the Vestibule 464

Operation 465

The Jansen Operation 465

Hinsberg's Operation 466

Richards's Operation 467

Neumann's Operation 468

Comparative Advantages and Disadvantages of the Different

Operations " 470

Author's Method of Reaching the Vestibule 470

Obliteration of the Vestibule for the Relief of Vertigo (Lake) 475

CHAPTER XVII Surgical Treatment of Infective Sigmoid Sinus Thrombosis 477

Sinus Operation for the Removal of an Infected Clot 479

Use of the Rongeur 481

Exploration of the Sinus 483

Resection of the Jugular Vein 485

Ligation of the Jugular Vein 488

Chapter XXII

Otologic Lessons of the World War. War Deafness: Deafness Due to Direct Labyrinthine Injury : Concussion Deafness : Psychic Deafness : Pithiatism: Simulation: Pithiatic Deafness: Diagnosis and Rationale OF Treatment 538

Deafness Due to Direct Cranial Injuries 539

Concussion Deafness Due to Explosions 541

Immunity of Static Labyrinth to Injury by Explosive Souistds 542

Prognosis as to Functional Improvement in Concussion Deafness 542

Chief Differential Point Between Profound Deafness Due to Direct

Labyrinthine Injury and to Concussion 542

Hysterical or Psychic Deafness; Psychic Mutism 543

Pithiatism, its Etiology and Clinical Significance. 543

Types of Pithiatic Deafness 544

Useful Diagnostic Tests 545

Rationale of Treatment 545