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278                                           THE EAR

discharge is often offensive, and this is found particularly in the chronic
infection which produces cholesteatoma, but also occurs in a purulent otitis
externa. A discharge of blood from the ear may arise acutely in an influenzal
infection or chronically from granulation tissue, but the possibility of
malignant disease must be kept in mind.

Pain. Pain in the ear may arise from the auricle, the external meatus or the
middle ear and mastoid, or it may be referred from other sources (Chapter 50).
Descriptions of pain vary. It may be lancinating and paroxysmal, severe and
constant, deep and boring, or intermittent. It may be aggravated by pressure
on the ear, by chewing, by sneezing or by blowing the nose. The patient
should be asked to point to the exact spot of the pain, because it may be felt
in front of the ear, or below the auricle, over the mastoid process or deep
within the meatus. Pain in front of the ear, in the region of the tragus, is
probably due to a furuncle, and this pain is aggravated by chewing, by lying
on the affected ear, by pressure over the tragus or by pulling the auricle. Pain
felt deep in the ear or behind it may arise from the middle ear or mastoid,
when it is increased by blowing the nose. Pain behind the ear may be due to an
infected gland at the mastoid tip, and this may have been caused by an
otitis externa, infections of the scalp or rubella. Pain located below the ear, in
the cleft between the ramus of the mandible and the mastoid process, is
frequently due to a Eustachian tubal infection, but it may arise in the parotid

Itching. Itching or irritation in the ear is generally associated with an otitis
externa, and it may be so severe that the patient is constantly rubbing or
scratching the ear, and may even abrade the skin at the meatal entrance. It
may arise from the discomfort of wax resulting in the patient attacking the wax
with a hair grip, matchstick or other such utensil, thus setting up an otitis

Tinnitus. Tinnitus, or a subjective sensation of sound in the ear, is a very
common, and sometimes the only, symptom of ear disease. Tinnitus may be
regarded as a sign of irritation of the cochlear mechanism, just as pain is a sign
of irritation of the sensory nerves. The sounds may be continuous or inter-
mittent, and they may be synchronous with the pulse. In otitis media pulsating
noises may be met with, but they commonly occur in the absence of any
aural disease. The patient is sometimes conscious of tinnitus during the whole
of his waking hours, or he may hear the noises only when in a quiet room or
when he is in bed at night. Tinnitus may produce extreme depression, and
may render the sufferer unfit for work. The nature of the sound varies. It may
be described as hissing, buzzing, rushing, hammering, as being like the escape
of steam, the sound of the sea, or of bells and so on. Tinnitus may be met with
in any form of ear disease, and is also a symptom of some general diseases
which indirectly affect the ear through the circulation. It is a common
symptom of renal affections, cardiac disease and anaemia, and it may be
caused by certain drugs, such as quinine, the salicylates and ototoxic anti-
biotics. The possibility of an intracranial tumour occurs to many patients,
and their fears cannot be allayed without a neurological examination unless
some other cause is found.

Vertigo. Vertigo may occur in certain ear diseases, and it must be regarded as a
symptom of irritation of the vestibular apparatus. Rarely it may be produced
by the pressure of cerumen against the tympanic membrane. It may accompany